With support from EMERSON, St. Louis, Missouri
OASIS’ health curriculum is the senior health promotion strategy of The OASIS Institute.
It offers a continuum of health courses and activities which encourage personal growth,
provide a social setting, and promote healthier lifestyles. OASIS members (age 50 and
older) explore personal motivations for becoming involved in health activities as well as
the barriers. They identify health risks and initiate action plans for making behavior
changes to manage them.
The purpose of the health curriculum strategy is to provide a well-rounded health
promotion program to older adults. The strategy is customized when implemented locally.
This allows OASIS Directors and Health Coordinators to offer a health curriculum most
meaningful to their membership. The OASIS Institute assists each site to implement the
program locally by providing training to the Health Coordinator and OASIS Director, as
well as helping them establish a local steering committee.
Each OASIS center offers health programming across many health topics. At the core of
the OASIS health curriculum are courses which support local health programming. The
OASIS Institute develops and distributes core courses to participating centers in these
seven key health promotion areas:
1. General Health Promotion
2. Physical Activity/Fitness
3. Nutrition
4. Mental Health/Wellness
5. Disease Management
6. Memory
7. Sensory Health
These seven areas form the core of a well-rounded health promotion program. Sites may
choose to offer their own courses in these areas or to offer core health curriculum provided
by The OASIS Institute or a combination of both. The goal is to ensure that courses are
offered in these areas which meet a wide variety of members’ needs.
The strategy for reaching a broad audience is based upon Dr. James O. Prochaska’s
Transtheoretical (Stages of Change) Model.1 Older adults can take part in health promotion
courses and activities no matter how ready they are to make changes in their health habits.
OASIS health curriculum embodies the first five stages of the Transtheoretical Model:
Not planning to address a health area
Thinking about starting
Making concrete plans to start
Taking action
Sustaining the action
By providing a well-rounded selection of courses across the stages of change, health
curriculum sites are maximizing the service they provide to older adults. Of health
curriculum, participants have said, ―
It got me moving and thinking about my overall health.
―
I learned some skills and ways to change some bad habits.‖ ―
I found motivation to start
moving again.‖ ―
It made me stop to think that age has nothing to do with really growing
old.‖
Building Bones is an exercise and education program to prevent or manage osteoporosis.
The program incorporates weight-bearing and resistance-training exercise, proper exercise
technique and comprehensive education on exercise and lifestyle modifications and
medical issues for people at risk for osteoporosis or fracture. The course has been taught at
the Tucson OASIS and Tucson Medical Center FitCenter since 1992 for frail adults and
healthy older adults, working within the group setting.
1
Prochaska, J. O., Norcross, J. C., & DiClemente, C. (1994). Changing for Good. New York:
William Morrow.
Jeannie Cooper, R.N., M.S., developed the original FitCenter and Tucson OASIS Better
Backs and Bones course in 1991. Her extensive 30-year careers as a registered nurse and
nurse practitioner, as well as her personal experience as an avid exerciser and exercise
physiologist combine to ensure the credibility and practicality of the popular program.
Jeannie received her nursing diploma from Milwaukee County Hospital in 1960, her family
health nurse practitioner certificate in 1975 from the University of Colorado, her B.S. in
nursing from Denver’s Metropolitan State College in 1980 and her M.S. in exercise science
from the University of Arizona in 1990. She is an ACE Certified Personal Trainer, a
certified Medical Exercise Specialist, a trainer for the National Arthritis Foundation
Arthritis Aquatic Program and a popular instructor at the TMC FitCenter. Jeannie is the
developer of the Building Bones curriculum education component.
The Tucson Medical Center FitCenter designs and delivers special population fitness
intervention programs to over 800 members at its hospital-based fitness center and to over
200 older adults at the Tucson OASIS and other satellite sites in Tucson, Arizona.
FitCenter specializes in exercise programming and instruction for people over age 50.
FitCenter is a member of the Therapy and Exercise Services Team at Tucson Medical
Center HealthCare, which includes inpatient, outpatient, adult and pediatric physical
therapy, occupational therapy, speech, audiology and cardiac rehabilitation. Tucson
Medical Center HealthCare is dedicated to improving quality of life for older adults with its
comprehensive maintenance, prevention and therapeutic exercise and wellness programs.
Donna Hartman, B.S., developed the Building Bones curriculum session plans and class
format. Donna received a B.S. in biology from the University of Arizona, is an ACE
Certified Aerobic Instructor and Personal Trainer, a certified Medical Exercise Specialist
and an Arthritis Foundation Aquatic and Land Program certified instructor. Over a period
of four years, Donna has refined and developed the Building Bones class format for both
the TMC FitCenter and Tucson OASIS programs.
Shelley Whitlatch, M.S., directs the TMC FitCenter and is the editor of the Building
Bones curriculum. Shelley received a B.S. in Physical Education from Iowa State
University, a M.S. in Exercise Science from the University of Arizona and has been a
developer and teacher of older adult fitness programs for over 15 years. She has extensive
experience in instructor training and development with Desert Southwest Fitness, Inc.
Materials for this course include the following:
• Building Bones course manual
• Sample class videotape
• Exercise and Osteoporosis: Exercise Programming for Optimal Bone Health.
By Gwen Hyatt, M.S.
• The Osteoporosis Handbook. By Sydney Lou Bonnick, M.D.Content
This Course Planning Guide is designed to introduce you to the philosophy and goals of the
OASIS health curriculum and to prepare you to teach Building Bones. As a fitness
instructor, you may or may not have experience teaching older adults. Class participants
may have a wide range of fitness levels and health. It is important to individualize this
course to address the needs of all participants. People who come to your sessions do
so because of a desire to increase their fitness so they can enjoy life. They have a
determination to improve, and research has shown that adults of all ages can improve
their fitness level through appropriate exercise.
This guide is divided into two major parts with information about instructing older adults in
exercise programs and course-specific information designed to provide you a greater
understanding of how to teach this course. The first part of this guide includes:
• An Aging Perspective
• Programming for Older Clients
• Tracking Outcomes
• Evaluation Components
• Instructor Resources
• Promotion
The second part provides planning and organizing suggestions specific to this course.
Accompanying the guide are session plans, mini-lectures, handouts and evaluations.
As you teach this course, be aware of the other health curriculum courses and activities that
are offered through OASIS. The OASIS Director or Health Coordinator can provide you
with a catalog of all the current offerings. As a fitness instructor, you may get questions
from your class members about nutrition, chronic diseases or other health issues. You have
the opportunity to direct your class members to other programs and activities that can help
them improve their health. The following are examples of classes that may be offered at
your site:
• Living Well with Chronic Conditions
• Improving Your Memory
• Taking Charge of Your Health
Your assistance in supporting all of the health curriculum courses and activities is
appreciated.
During the next 30 years, the number of Americans over the age of 50 will increase by
74%, while the population under 50 will grow by 1%. The fastest growing segment of the
population is over the age of 85. With the explosion in numbers of older adults, health
issues and how to prevent them become important on a national level. At the forefront of
research is the importance of exercise for healthy aging. According to the Surgeon
General’s 1996 Report on Physical Activity, only 15% of American adults participate in
vigorous physical activity regularly, 22% get any regular physical activity and older adults
probably have even lower rates of activity.
In spite of these discouraging figures, more and more older adults are becoming involved
in exercise as they understand the importance of exercise in maintaining independence and
health. The needs and interests of this population differ from younger adults. Your beliefs
and expectations about aging will greatly influence your effectiveness as an instructor with
this age group. An Aging Perspective helps you explore your attitudes toward aging and
learn some of the facts so that you can bring more credibility to your class.
Take five minutes and write down on a piece of paper as many words and phrases as you
can think of to describe aging and older people. If you have experience working with
seniors, your list probably has both positive and negative items. If you are new to this
group, you may be surprised at how the negative stereotypes of this age group have
influenced your view. Look for the following words on your list:
disease
sick
frail
weak
sexless
Were you missing possible positive images of aging? These could include:
growth
wisdom
caring
active
Many of us have developed negative images of aging and may even fear growing old.
Perceptions of reality influence experience. How a person perceives the world is how the
person experiences the world. Perceptions are a learned phenomenon; if you change your
perceptions, you literally change your experience and behavior. Therefore, our perceptions
about aging, our beliefs and expectations about aging can profoundly influence the way we
experience aging (Nelson & Economos, 1994).
Challenge your attitudes and beliefs about aging. Think about older adults you have
known in your life. Does your list describe these people? Now think about what you will
be like at 75. Does your list describe what you will be like? As you get to know older
adults, through teaching, you will gain firsthand knowledge for a realistic view of aging.
The most common myths and misconceptions about aging include the following:
All older people are alike.
Older adults are happy people, sad people, executives, shoppers, gardeners, conservatives
and liberals. Older adults are fitness instructors, actresses, waiters and engineers. They are
widows surviving on Social Security and couples living in their own homes. There is such
a wide range for what is normal that no one description fits.
Most older people live in nursing homes.
Ninety-five per cent of older adults at any one time live on their own in the community.
Older people are physically weak, disabled or sick.
Seven out of ten older people rate their health as very good or excellent, in spite of fact that
80% of people over the age of 65 have two or more chronic diseases.
Older people are not as mentally sharp as younger people.
It may take longer for older adults to learn new things, but they retain them as well as
younger people, once learned.
Older people are rigid and set in their ways or cranky and demanding.
Personality tends to stay the same. If old people are cranky, they were probably
always cranky.
Older people have lost their sexual urge and are not very sexy.
In fact, most people maintain an interest and ability for sexual relations throughout life.
Aging is a unique process experienced by all living things; there are losses, changes and
readjustment periods. Its characteristics and outcomes are as individual as the personality
of the aging person. There is also the opportunity for growth. Losses and limitations can
create breakthroughs for new experiences. It is one’s attitude toward what can be done that
becomes important. People may choose to take control of their health or set goals to do
new things. These goals could include exercise or regular physical activity. You may see
an 80-year-old who comes to class to stay independent or to be able to go on a hike with
her grandchild. Exercise often becomes a means to an end and a part of the process of
reaching important life goals. You have the opportunity to work with this dynamic group
of individuals and help them to reach their goals. We hope that you will take into your
classes an aging perspective that promotes success for you and your clients.
Most of the decline in strength and efficiency older people experience is the result of being
out of shape, rather than the effects of aging alone. These normal changes, however, are
often amplified by disease processes, and we need to be mindful of them as we plan
exercise programs. Table 1 provides a summary of changes associated with aging and their
implications for programming.
Bortz, W. M. (1996). Dare To Be 100, New York: Simon & Schuster.
Evans, W. & Rosenberg, I. H. (199). Biomarkers: The 10 Keys to Prolonging Vitality.
New York: Simon & Schuster.
Nelson, M. & Economos, C. (1994). Behind the research: Empowering the elderly.
The KEISER Letter, 1 (2).
Rowe, J. W. & Kahn, R. L. (1988). Successful Aging. New York: Pantheon.
Spirduso, W. (1995). Physical Dimensions of Aging. Champaign, IL: Human Kinetics.
U. S. Department of Health and Human Services. (1996). Physical Activity and Health:
A Report of the Surgeon General, Washington, DC.
Functional fitness is defined as increasing the body’s physiological, psychological and
spiritual systems to their maximum efficiency (see the article from ACE Certified News
following this page). The end result is improved health, ability to perform activities of
daily living, enhanced quality of life and independence. The functional fitness concept is a
better model for working with older adults when compared with the usual health club
model. Table 2 shows the usual focus on appearance and competition that is rarely useful
with older adults.
Most of our older participants have a goal of staying independent in their daily lives. The
exercise programs developed for OASIS support the functional fitness concept. As you
read the curriculum for the various exercise programs, you will see an emphasis on training
that is important for maintaining mobility and activities that support daily living.
At the 20th National Wellness Conference in Steven’s Point, Wisconsin, keynote speaker
Richard Keeling challenged the fitness industry, asking, ―
Fitness for what?‖ Keeling
described fitness as it is most frequently depicted: fitness for sex appeal, looking young,
getting thin and building bulging muscles. But is this the best goal for our industry? Can’t
ACE certified Professionals help accomplish the following goals?
1. appeal to the fitness market in a different way
2. improve the health of individuals and the community
3. play a credible, integral role in health-care reform
4. serve the sedentary or aging population
The ultimate success of the fitness industry may lie in the ability to effectively improve
function. The end result is improved health, the ability to perform activities of daily living,
enhance the quality of life, and independence. The table on the prior page (Characteristics
of Two Models of Fitness) compares characteristics of a Functional Fitness Model to the
Traditional Health Club Model of fitness. Where does your club or program fit into this
comparison?
The key processes of our fitness business will change as we begin to focus more on
functional fitness. Program design objectives, measurement and evaluation and
motivational strategies are all an integral part of adapting to this new focus. The key is to
develop new ideas for program design. As you design new programs, focus on disease or
risk factors, or a specific activity of daily living. Examples might include
•―
Building Bones‖ might be a strength and education program for people with
osteoporosis
•―
Better Backs‖ could target people with chronic back problems and work on strength and
flexibility for back stabilization
•―
Aqua Hips‖ might emphasize range of motion and strength for people with hip or knee
problems
•―
Weight Training for People with Arthritis‖ would focus on the major muscles that
support joints
Measurement of outcomes must be built into the programs from the very beginning.
Establish functional goals that are objective and measurable such as reduced blood
pressure, increased range of motion, increased amount of weight or number of repetitions,
and increased self-esteem. Clients can progress to more advanced classes as goals are met
or reestablished.
If you have a client who is recovering from a knee injury or surgery, You might start them
out in a water exercise program, move on to specific weight raining, then finally help them
maintain strength and conditioning by introducing them to a step-training class or interval
workout. How and when they progress from one class to the next might be measured by
increased range of motion at the knee, decreased knee pain, as well as increased walking
speed. These measurements document the effectiveness and specificity of the training that
your clients have received.
Motivation to begin and continue an exercise program is usually a matter of setting and
achieving goals. Being able to get up from a low, soft sofa, carry luggage on a trip or
remain pain free after a back injury can be motivating indicators in developing the exercise
habit even in the most sedentary individuals. Once they realize that they must continue
exercising in order to maintain a given level of functional ability, motivation to exercise
often takes care of itself.
But even motivation to increase functional ability isn’t enough without this primary factor:
fun. Making exercise something to look forward to can be a challenge, particularly for
those who can’t seem to find any enjoyment in moving their bodies. Without fun,
regardless of how good it might be for them, few people are able to stick to a program of
regular exercise for any length of time. Once exercise becomes an enjoyable experience,
individuals can’t help but notice how much better they begin to fee.
The challenge for fitness professionals like you is to recognize your role and responsibility
in affective a positive health change in people and in your communities. Fitness must be
seen as a means to an end, not the end itself. And it all begins with each onus, acting as
responsible fitness professionals, taking it one step, one client at a time.
*Adapted from an article by Shelley Whitlatch in Ace Certified News, Vol 2, No.3, April/May, 1996.
This section outlines five key aspects of teaching exercise programs to older adults. Also
included is a chart reviewing effective cuing and a section on safety precautions regarding
exercises for older adults and those with special conditions. The outline covers the
following:
• The Role of the Leader
• Main Domains or Styles of Learning Movement
• Teaching Movement Progressions
• Evaluating Your Teaching Methods
• Safety and Liability Issues
The instructor takes on multiple roles when working with an older population:
LEADER
providing direction
HELPER
individualizing programs
TEACHER
providing instruction
FRIEND
giving support
Visual Learning (observation)
• Primary in learning movement skills.
• Most people will learn by mimicking or following the leader’s demonstration
of movements.
• Non-verbal cues include the following: arm and body signals, eye contact,
and facial expressions.
Implications for Teaching:
• Use exaggerated movements to demonstrate small movements.
• Make precise, definitive movements to demonstrate technique.
• Model proper execution and technique of movement.
Verbal Learning
• Secondary in learning movement skills, but still vital.
• Use verbal cues for anticipatory signaling.
• Be aware of hearing loss in older adults.
Implications for Teaching:
• Use clear, concise, slow speech, lower pitched voice.
• Face class so lips can be read.
• Place those with hearing loss in appropriate place.
• Consider music volume.
• Help students keep beat/tempo.
• Use directional verbal cues instead of counting (―
up, up, down‖).
• Use descriptive verbal cues (―
step, cross, step, touch‖) or (―
left side, tap center‖).
• Use precise, concise cues.
• Cue well before the next action on counts 5, 6 and 7 of the 8 count.
• Cue in rhythm with the music to help students stay on beat.
Tactile or Hands-on Cuing
• Some people will benefit from additional types of cuing.
• Assist participants with kinesthetic awareness with touch.
• Use for individualization.
• Be sensitive to student physical restrictions.
Part Whole Learning vs. Whole Part Learning
• Break combinations down into parts.
• Introduce the parts over time, either days or weeks.
• Start with core movements and add additional movements.
Start Simple and Move to Complex
• Use basic movements and combine them in interesting ways.
• Do include complex movement patterns as the challenging progresses.
Go from Slow to Fast
• Always start slow, both when introducing a movement and during each class.
• Increase speed only if appropriate in terms of safety and need for additional
challenge.
• Slow movements are often more intense and utilize better techniques.
• Notice motor pathways developing over time.
Visual Demonstrations
• Role model different levels.
• The fragile/ beginning students will need more modeling than the more experienced
student.
• Place students so that instructor can be easily seen and assistance given.
• Mirror students when facing the group (for safety, you should always face the group
when no mirrors are present).
Verbal Cuing
• Use cues that work for both sitting and standing students.
• Role model low-level while cuing higher-level.
• Use group corrections (verbal and visual) when you see individuals performing
incorrectly.
Individualization
• Speak with students before and after class to discuss individual concerns or exercise
modifications.
• Make eye contact with students as you cue corrections.
• Move through the class. Use different formations like circles, lines, etc.
• Be aware of exercises that may be difficult or compromising.
• Give appropriate exercise modifications that work the same objective.
• Give positive reinforcement as you teach.
Evaluating Your Teaching Methods
• Feedback is important to improve your teaching skill.
• It is impossible to teach without learning, if open to doing so.
• Methods you can use to evaluate your classes:
- Verbal feedback from students
- Attendance at 80-90%
- Written class evaluations
- Peer and administrative evaluations
- Self audiotape or videotape
- Functional fitness level of students
The OASIS Institute provides pre-/post-questionnaires and a functional fitness form to
track exercise participants. These are described in the Tracking Functional Improvement
portion of this guide.
Waiver
A waiver is to be obtained from all participants in physical activity courses. There is a
sample at the end of this section. Check with your local site coordinator or director to see
if there is a form specific for your site and the procedures for handling the forms.
Health History
It is helpful to have your participants complete a health history to find out any special
conditions or problems that they might have. A sample form is included at the end of this
section. Review the forms for your class participants. Participants can be asked to update
the forms at the beginning of each course.
Promotion
A description of this course, along with a sample flyer suitable for photocopying, appears
at the end of this section. Please also consult the OASIS Director or Coordinator for
additional materials in the Health Curriculum Coordinator Handbook.
Remember that effective cuing takes practice and thought. These techniques will help you
build your cuing skills for working with older adults.
1. No cues, students mimic movements
2. Numerically count beats or steps
3. Count plus directional cues on counts 7 and 8
4. Directional cues and body technique cues
5. Verbal and nonverbal directional cues, technique refinements and individual
corrections continuously
The final material for this section was compiled by Tucson Medical Center FitCenter.
There are safety recommendations for specific exercises as well as recommendations for
people with specific conditions.
The American Council on Exercise (ACE) recommends avoiding the following exercises
for any population:
• Yoga plow position
• Straight sit-ups
• Double leg raises in any position
• Full neck/head circles
• Spinal hyperextension
The Fit Center at Tucson Medical Center (TMC) recommends avoiding:
• Unsupported forward flexion of the spine
• Hamstring stretch
• Ballistic stretching
• Knee hyperextension
• More than four successive foot-to-floor impacts per foot
Exercises TMC deems risky or compromising for clients:
•Double arm or double leg lifts in the prone position
• Standing toe touch
• Rapid trunk rotation
• Kneeling side leg lifts (fire hydrants) with straight leg or uncontrolled
swinging of the leg
• Donkey kicks in kneeling position; controlled hip hyperextension may
be appropriate
• Straight sit-ups
• Hip flexor stretch with a deep front lunge position
• Side-to-side whipping motions of body or limbs
• Sustained isometric contractions
• Side leg raises in the piked position
• Full jumping jacks
• More than 16-24 repetitions of a single exercise/muscle group
Another exercise that may be contraindicated:
• Extreme/unsupported lateral trunk flexion
Contraindications:
• High impact movement, i.e. jumping, jogging, stamping, stepping
• Spinal flexion, i.e. crunches, rowing machine, seated flexion
• Resisted hip abduction/adduction, one-legged standing
• Assisted neck flexion or rotation
• To reduce the risk of falls, avoid exercise on slippery floors
Recommendations:
• Weight bearing activity, i.e. walking, dancing, racquet sports
• Resistive training, including specific exercise that place mild mechanical stress on the
spine, femoral neck and distal radius
• Aquatic strengthening exercises
• Back extension and scapula retraction
Contraindications:
• Hip flexion greater than 90 degrees
• Internal rotation of foot and/or leg
• Hip adduction past midline
Recommendations:
• Lateral movement, strengthening hip abduction
• Strengthening of external hip rotators and extensors
Contraindications:
• High impact movement
• Exercise in the heat
Recommendations:
• Work out aerobically at lower level for a longer duration, with
conscientious monitoring
• Concentrate on quality vs. quantity of movement to increase workout
• Increase resistive exercise work
• Initiate exercise with accumulated exercise throughout the day
Contraindications:
• No exercise if client has asthmatic symptoms prior to activity
• Stop exercise immediately if asthmatic symptoms occur
Recommendations:
• Modify exercise if client is tired or if conditions are cold, snowy or humid
• Urge use of medication/inhaler 30-60 minutes prior to exercise
• Reduce or delete arm movements above shoulder level
• Focus on large muscle groups of the lower body
• Use quality movements vs. quantity to increase workload
• Encourage clients not to smoke one hour before or after exercise
• Educate clients that exercise will improve endurance
• Use breathing exercises to strengthen intercostals muscles
• Use progressive endurance exercise
Contraindications:
• Isometric exercises
• Heavy weightlifting
• Avoid exercise if blood pressure is not controlled
• Terminate exercise in the event of:
- Angina
- Shortness of breath
- Dizziness
- Leg pain or cramping
- Cold sweat
- Failure of heart rate to increase with increasing workload
- Inappropriate bradycardia (resting heart rate of under 60 beats per minute)
- Failure of systolic blood pressure to increase with exercise
Recommendations:
• Limit arm work above shoulder level
• Focus on endurance strengthening of low to moderate intensity
• Incorporate interval training
• Utilize larger, more gradual warm-ups and cool-downs (20 minutes)
Contraindications:
• Any exercise if the disease is not under control
• Encourage treadmill test by participants
Recommendations:
• Endurance and strength training
• Forming regular, predictable exercise habits
Contraindications:
• Avoid aerobic and resistive exercises during an acute inflammatory period
• Vigorous exercise may be contraindicated for those with systemic effects such
as heart or lung involvement
Recommendations:
• Range of motion and strengthening exercises
• Activities that minimize weight bearing, i.e. swimming
• Weight reduction if needed to reduce stress on joints
• Attention to posture and body mechanics
Contraindications:
• Unsupported forward flexion
• No twisting at waist
• No double leg-lifts, prone or supine
Recommendations:
• Back stabilization exercises
• Strength exercises
• Flexibility exercises
To assist in tracking outcomes for participants in health curriculum exercise courses, a
series of performance tests are completed at the beginning and end of each session. These
tests provide objective documentation of changes and have benefits for the participant,
instructor and OASIS.
For the participant:
• Objectively document improvement
- Establishes a baseline
- Assists in setting reasonable goals
- Shows progress
• Improves compliance in attending exercise sessions
• Motivates to continue classes or progress to another level
• Educates about functional abilities
• Reinforces the role of fitness and prevention as part of a healthy lifestyle
• Empowers to make healthy choices in management of chronic conditions
For the instructor:
• Identifies the fitness and health needs of individuals
• Screens for risks or physical problems
• Establishes the knowledge level of participants
• Provides feedback on the effectiveness of the course
• Provides data for progressing the individual or class
For OASIS:
• Provides baseline data
• Objectively tracks participants’ functional level
• Provides data for program planning
• Documents the role of OASIS in improving the health and disease management
of participants
• Documents the effectiveness of exercise to sponsors
The outcomes measured for health curriculum exercise courses not only include both the
usual pre- and post- course evaluations used for all health and wellness classes, but also
some functional fitness performance measures specific to the objectives and exercise
activities of each class.
Oasis Health Curriculum Evaluations
• Pre-questionnaire: Building Bones Course Questionnaire
• Post-questionnaire: Building Bones Course Evaluation
Functional Fitness Outcome Measures
• Endurance tests
- Two Minute Step in Place
• Flexibility tests
- Back Scratch Test
- Chair Sit-and-Reach
• Strength tests
- Arm Curl
- Chair Stand
• Balance test
- 8 Foot Up-and-Go
• All exercise participants should be tested at the beginning and end of each course.
• In order to allow time for improvements or noticeable changes, it is recommended
that pre- and post-testing be a minimum of eight weeks apart. If a course is split into
two sections, then participants should be tested three times, at the beginning of the
course, the end of the first section and again at the end of the second section.
• The standardized procedures for conducting each test, including administration,
scoring and equipment, are at the end of this section.
• Review and become familiar with the protocol of each test.
• Give the test in the same way for each test and each participant.
• Volunteers can be used to assist with testing but should be trained in protocols and
any equipment needed, such as a stopwatch.
• Use the same equipment and set-up for each test session.
• Allow participants to practice the activity once before conducting the timed tests.
• An assessment form is included in this section for recording and tracking
participants’ test results. These will be copied and turned in to The OASIS Institute
and compiled with participants across the country.
You may copy the test forms for participants if they would like to keep track of their
functional improvement over time.
If a participant has been tested recently at the end of an exercise session, then begins a new
session, you can use their post test as the baseline for the next session of exercise.
Scheduling: Conduct the assessments during the first and last class sessions.
Staffing the Assessments: One instructor and 2-4 additional helpers are needed during
the testing. The site coordinator and volunteers can be trained to assist with testing
through demonstration and practice with the protocols and equipment. Participants
may be able to measure each other for some of the tests, e.g., the chair stand-ups.
You can assign partners who watch and count for each other, then switch.
Space and Equipment: Stations for each of the tests to be done should be set up with a
table for recording results and chairs for waiting or use in the tests. You may want to
set up an exercise box for each exercise center with materials for testing and classes:
• Pre- and post-evaluation forms
• Outcome measures forms
• Pens or pencils, clipboards
• Stop-watch
• Laminated copies of the testing protocols
• Ruler for flexibility measurements
• Cone for 8 foot up-and-go test
• Masking tape for marking floor, setting tape measure and cone
• Music or relaxation tapes, depending on the classes being offered
• Tape measure for functional reach
Record-keeping: Check the data forms after the testing session for errors and make
corrections or clarifications. Store in a safe, accessible location (possibly a file in
exercise box). Compile the data and prepare a report for the health curriculum
Director and Coordinator.
• Draw a diagram of the testing station set-up.
• Determine how you will split up the group.
• Be aware that older participants may be nervous about being tested.
• Be serious, but allow the environment to be upbeat and social.
• Use the assessment session as a time for education.
• A handout explaining the testing is included at the end of this section and can be
copied and given to course participants.
The following are specific directions for administering each of the test items. To assure
scoring accuracy and interpretation, strict adherence to all test instructions is essential.
Throughout all testing, participants should be instructed to “do the best they can on the
tests, but to never push themselves to a point of over exertion or beyond what they think is
safe for them.” Prior to testing, people need to participate in a 5-10 minute warm-up and
general stretch routine.
Based on guidelines established by the American College of Sports Medicine (1995) and
on input from our medical consultants, these tests are safe for the majority of communityresiding older adults without medical screening, and pose risks similar to engaging in
moderate physical activity. Persons who should not take the tests without physician
approval are those who:
• have been advised by their doctors not to exercise because of a medical
condition
• are currently experiencing chest pain, dizziness, or have exertional angina
(chest tightness, pressure, pain, heaviness) during exercise
• have experienced congestive heart failure or have uncontrolled high blood
pressure (greater than 160/100).
Purpose:
To assess lower body strength.
Equipment:
Stopwatch, straight back or folding chair (without arms) seat height
approximately 17 inches. For safety purposes, the chair should be placed
against a wall, or in some other way stabilized, to prevent it from moving
during the test.
Protocol:
The test begins with the participant seated in the middle of the chair, back
straight, and feet flat on the floor. Arms are crossed at the wrists and held
against the chest. On the signal ―
go‖ the participant rises to a full stand and
returns back to a fully seated position. The participant is encouraged to
complete as many full stands as possible within a 30-second time limit.
Following a demonstration by the tester, a practice trial of one or two repetitions
should be given to check for proper form, followed by one 30-second test trial.
Scoring:
The score is the total number of stands executed correctly within 30 seconds. If the
participant is more than half way up at the end of 30 seconds, it counts as a full stand.
Purpose:
To assess upper body strength.
Equipment:
Wrist watch with second hand, straight back or folding chair
(without arms), hand weights—dumbbells 5 lbs. (2.27 kg.)
for women and 8 lbs. (3.63 kg) for men.
Protocol:
The participant is seated on a chair, back straight and feet
flat on the floor, and with the dominant side of the body
close to the edge. The weight is held at the side in the
dominant hand (handshake grip). The test begins with the
arm in the down position beside the chair, perpendicular to
the floor. At the signal ―
go‖ the participant turns the palm
up while curling the arm through a full range of motion,
and then returns to the fully extended position. At the
down position the weight should have returned to the
handshake grip position.
The examiner kneels (or sits in a chair) next to the participant
on the dominant arm side, placing his/her fingers on the
person’s mid bicep to stabilize the upper arm from moving,
and to assure that a full curl is made (participant’s forearm
should squeeze examiner’s fingers). It is important that the
participant’s upper arm remains stabilized (still) throughout
the test.
The examiner may also need to position his/her other hand
behind the elbow so that the person will know when full
extension has been reached, and to prevent a ―
back swinging
motion‖ of the arm.
The participant is encouraged to execute as many curls as possible within the 30-second
time limit.
Following a demonstration by the examiner, a practice trial of one or two repetitions should
be given to check for proper form, followed by one 30-second trial.
Scoring:
The score is the total number of curls made correctly within 30 seconds. If the arm is more
than half way up at the end of the 30 seconds, it counts as a curl.
Purpose:
To assess physical mobility--involves power, speed, agility, and dynamic balance.
Equipment:
Stop watch, tape measure, cone (or similar marker), and straight back or folding chair,
approximate seat height seat 17 inches (43.18 cm).
Set-up:
The chair should be positioned against a wall or in some other way secured so that it does
not move during the testing. The chair should also be in a clear, unobstructed area, facing
a cone marker exactly 8 feet (2.44 m) away (measured from a point on the floor even with
the front edge of the chair to the back of the marker). There should be at least 4 feet
(1.22 m) of clearance beyond the cone to allow ample turning room for the participant.
Protocol:
The test begins with the participant fully seated in the chair
(erect posture), hands on thighs, and feet flat on the floor
(one foot slightly in front of the other). On the signal ―
go‖
the person gets up from the chair (may push off thighs or
chair), walks as quickly as possible around the cone (either
side), and returns to the chair. The participant should be told
that this is a ―
timed‖ test and that the object is to walk as
quickly as possible (without running) around the cone and
back to the chair. The tester should serve as a ―
spotter,‖
standing midway between the chair and the cone, ready to
assist the participant, in case of a loss of balance. For reliable
scoring, the tester must start the timer on ―
go‖ whether or not
the person has started to move, and ―
stop‖ the timer at the
exact instant the person sits in the chair.
Following a demonstration, the participant should walk
through the test one time as a practice, and then is given two
test trials. Participants should be reminded that the time does
not stop until they are fully seated in the chair.
Scoring:
The score is the time elapsed from the signal ―
go‖ until the subject returns to a seated
position on the chair. Record both test scores to the nearest tenth of a second and circle the
―
best‖ score (lowest time). The ―
best‖ score is used to evaluate performance.
Purpose:
An alternative test to assess aerobic endurance
Equipment:
Stop watch, tape measure or 30-inch (76.2-cm)
piece of cord, masking tape, and a mechanical
counter (if possible) to insure accurate counting
of steps.
Set-up:
The proper (minimum) knee stepping height for
each participant is at a level even with the mid-way
point between the patella (middle of the knee cap)
and the iliac crest (top hip bone). This point can be determined using a tape measure, or by
simply stretching a piece of cord from the patella to the iliac crest, then doubling it over to
determine the mid-way point. To monitor correct knee height when stepping, books can be
stacked on an adjacent table, or a ruler can be attached to a chair or wall with masking tape
marking the proper knee height.
Protocol:
On the signal ―
go‖ the participant begins stepping (not running) in place, starting with the
right leg, and continues as many steps as possible within the time period. Although both
knees must be raised to the correct height to be counted, the tester only counts the
number of times the right knee reaches the correct height. The counter also serves as a
spotter in case of loss of balance and assures that the subject maintains proper knee height.
As soon as proper knee height cannot be maintained, the participant is asked to stop--or to
stop and rest until proper form can be regained. Stepping may be resumed if the 2-minute
time period has not elapsed. If necessary, one hand can be placed on the table or chair to
assist in maintaining balance.
To assist with proper pacing and to improve scoring accuracy, a practice test should be
given prior to the test day. On test day, the examiner should demonstrate the procedure and
allow the participants to practice briefly to recheck their understanding of the protocol.
Safety:
At the end of the test the participant should slowly walk around for about a minute to cooldown.
Scoring:
The score is the total number of times the right knee reaches the minimum height. To
assist with pacing, subjects should be told when one minute has passed and when there are
30 seconds to go.
Purpose:
To assess upper body (shoulder) flexibility.
Equipment:
18-inch ruler (45.72 cm) (half of a yardstick).
Protocol:
In a standing position, the participant places the preferred
hand* over the same shoulder, palm down and fingers
extended, reaching down the middle of the back as far as
possible (elbow pointed up). The hand of other arm is
placed behind back, palm up, reaching up as far as
possible in an attempt to touch or overlap the extended
middle fingers of both hands.
Without moving the participant’s hands, the tester helps to see that the middle fingers of
each hand are directed toward each other. The participants are not allowed to grab their
fingers together and pull.
Following a demonstration by the tester, the participant is asked to determine the preferred
hand. The participant is then given two practice (stretching) trials, followed by two test
trials.
Scoring:
The distance of overlap, or distance between the tips of the middle fingers is measured to
the nearest 1/2 inch (1 cm). Minus scores (-) are given to represent the distance short of
touching middle fingers; plus scores (+) represent the degree of overlap of middle fingers.
Record both test scores and circle the ―
best‖ score. The ―
best‖ score is used to evaluate
performance. Be sure to indicate minus or plus on the score card.
* The preferred hand is defined as the one which results in the better score. Although, it is
important to work on flexibility on both sides of the body, only the ―
better‖ has been used
in developing norms.
Purpose:
To assess lower body
(primarily hamstring) flexibility.
Equipment:
Straight back or folding chair with an
approx. 17-inch (43.18-cm) seat height,
and an 18-inch (45.72-cm) ruler. For safety
purposes, the chair should be placed against
a wall and checked to see that it remains
stable (doesn’t tip forward) when the person
sits on the front edge.
Protocol:
Starting in a sitting position on a chair, the participant moves forward until she/he is sitting
on the front edge of the chair. The crease between the top of the leg and the buttocks
should be even with the edge of the chair seat. Keeping one leg bent and foot flat on the
floor, the other leg (the preferred leg*) is extended straight in front of the hip, with heel on
floor and foot flexed (at approx. 90°, refer to picture).
With the extended leg as straight as possible (but not hyperextended), the participant
slowly bends forward at the hip joint (spine should remain as straight as possible, with the
head in line with spine, not tucked) sliding the hands (one on top of the other with the tips
of the middle fingers even) down the extended leg in an attempt to touch the toes. The
reach must be held for two seconds. If the extended knee starts to bend, ask the participant
to slowly sit back until knee is straight before scoring. Participants should be reminded to
exhale as they bend forward, avoid bouncing or rapid, forceful movements, and never
stretch to the point of pain.
Following a demonstration by the tester, the participant is asked to determine the preferred
leg. The participant is then given two practice (stretching) trials on that leg, followed by
two test trials.
Scoring:
Using an 18-inch (45.72-cm) ruler, the scorer records the number of inches a person is
short of reaching the toe (minus score) or reaches beyond the toe (plus score). The middle
of the toe at the end of the shoe represents a zero score. Record both test scores to the
nearest 1/2 inch (1 cm), and circle the ―
best‖ score. The ―
best‖ score is used to evaluate
performance. Be sure to indicate ―
minus‖ or ―
plus‖ on the score card.
* The preferred leg is defined as the one which results in the better score. Obviously, it is
important to work on flexibility on both sides of the body, but for the sake of time, only the
―
better‖ side has been used in developing norms.
Q. What are we testing?
A. We are testing the key outcomes of our fitness classes: increased muscle strength and
better flexibility and endurance. Classes with special goals, such as improving balance,
may have additional measures. One or two tests for each outcome may be used to test
important muscle groups. For example: the Chair Stand test measures the strength of the
quadriceps muscles in the legs. These muscles are important for daily functions such as
walking and getting in and out of a chair. A walking or stepping test is used to evaluate
heart and lung endurance.
Q. Why do we test?
A. The initial tests help us in determining your strengths and weaknesses so that the classes
are designed to meet your needs. The follow-up tests tell us whether you are improving
and document the progress you have made. We can identify areas that are progressing and
areas that need additional work. This helps the instructor evaluate the class content and
determines if the right combination of exercises are being included.
Q. Who is tested, and how often?
A. All participants in exercise classes are tested at the beginning and end of each session.
Q. How are the results used?
A. Besides giving you and the instructor feedback about your progress, OASIS uses the
results to get support for their exercise courses and show sponsors the improvements that
people can make by participating in this program.
• Functional Fitness tests are objective measures of physical abilities needed to carry out
daily tasks safely and independently
• Research has shown that much of the physical decline associated with aging is
preventable and even reversible! Performance on these tests allows individuals to track
changes over time and compare performance with individuals of the same age and gender.
• Check your fitness scores and see how you change using this form.
To find out how well you did on each test, find your age group on the chart below. Then look to see whether your score on each test falls
within the numbers printed for your age. Scores within the ranges listed below are considered to be in the normal range for your age
group. Lower scores are below average; higher scores are above average.
*These standards were derived from test scores collected from a group of 7,000 healthy, active people who weren’t homebound.
The following description may be modified or used as written in the OASIS course catalog,
on flyers or posters, on a web page, et cetera, to describe Building Bones.
If you have osteoporosis or are at risk, this course is for you. Learn exercises to strengthen
muscles and bones and what you can do to prevent osteoporosis.
Building Bones is a safe, beginning-level strength and flexibility class. It includes
functional resistance exercises for the major muscles, stressing correct exercise technique
and good posture, as well as balance, range of motion and stretching drills. Emphasis is on
weight-bearing activities with motivational music and social interaction.
There are several objectives for participants of this course:
• To increase self-knowledge about osteoporosis
• To increase functional strength for upper and lower body
• To demonstrate compliance to an exercise program
This course meets two to three times per week for sessions of 50 to 60 minutes. Each class
includes 45 to 50 minutes of exercise and five minutes of education. Exercises include
warm-up, strength and stretching activities for the upper and lower body and information to
increase understanding of osteoporosis. Exercises can be done seated, as well as standing.
These materials include information for mini-lectures and accompanying handouts for
participants. Instructors are encouraged to review the written materials accompanying this
manual to develop a good understanding of osteoporosis and its treatment, as well as the
relationship of osteoporosis and exercise.
You may need to modify the exercise program based on a number of factors, including the
amount of time each exercise takes in your class. You may delete or add exercises as you
determine what is appropriate for your class.
The warm-up needs to be long enough to assure good circulation, at least 12 minutes and
preferably 15 minutes.
Sideways movement presents a risk for tripping. It is an important skill, but practicing it
may be hazardous. Be aware of those people who are at highest risk for falling. Provide
enough space to walk near a wall or line up chairs along the path.
During the warm-up or any locomotor portion, be sure pace is appropriate (116-124 BPM).
Err on the side of easy. Provide additional challenges for the more advanced participants.
Use music with which participants are comfortable. You may think that 70s music is old
but your participants may tell you that it is not old enough. Try big band and swing music
from the 30s and 40s. Musicals and movie themes are also appropriate. Keep the volume
low so that participants can hear you and it does not disturb those with hearing aids. A list
of music suggestions is included on the following page.
One straight-backed chair per person. Chairs should be arranged so that all participants can
see you and you can see them. All bags, purses, jackets and other personal items should be
placed to the side, away from the exercise space. Chairs need to be heavy enough and
stable enough to provide safe support.
A large open space of 1,000 to 1,500 sq. ft. is recommended. General guidelines for
strength activity space include a 6x6 space for each person, or about 16 people per
1,000 sq. ft. Concrete (even with vinyl flooring on top) can be damaging to the body.
Avoid extended walking or standing on this type of floor. If the floor is carpeted, be
particularly cautious to avoid shoes that stick. On all surfaces, be sure there are no
wet, slippery or sticky spots that may cause a fall.
Be sure weights and resistance equipment are appropriate for the individual. Some may not
be able to grasp weights or Dynabands due to arthritis or other conditions. You may want
to use baggies with rice or heavier materials and stuffed in tube socks. Tie the end of the
sock. These weights can be held by most participants, can be draped over ankles and more
than one can be grasped in each hand.
The following are companies that sell music tapes for exercise classes and home exercise,
and suggestions from prior instructors of their products that may work for your class. Most
of these companies offer a variety of music options and have websites where you can see
their products.
9411 Philadelphia Rd.
Baltimore, MD 21237
1-800-843-6499
www.dynamix-music.com
Examples: Hit Parade, Fabulous 50s
Box 769689
Roswell, GA 30076
1-800-878-4764
www.sportsmusic.com
Examples: Big Band Step, Country Step
P.O. Box 533967
Orlando, FL 32853
www.musclemixesmusic.com
Examples: Fit Over 50, Silver Sneakers
P.O. Box 454
Twin Falls, ID 83303
1-208-734-8668
www.channelproductions.com
Examples: Quiet Colors- Kelly Yost, Roses and Solitude - Kelly Yost
Before starting, remind participants about correct posture, feet placement and breathing.
Feet slightly wider than hip distance apart, toes and knees in same direction (pointing
forward or out at a slight angle); inhale as arms reach overhead, palms facing each other,
and exhale as arms return to side; repeat inhale with tops of the hands closing toward each
other overhead, exhaling as arms lower.
Each segment is designed to use both arms and legs for a warm up that targets the large
muscle groups of the body. Combine two three minute segments at the beginning of each
session for a warm up.
• Right to left in place, gradually increasing knee flexion until marching in place
• Continue marching, moving feet wider apart, arms pumping
• March eight counts wide, eight counts center
• March four counts wide, four counts center
• March two counts wide, two counts center
• March forward with arms punching forward from shoulders; March back with arms
pulling back
• March forward wide with arms opening diagonally at waist height; March back with
arms pulling in
• March feet hip width apart, stop march, move both feet toes-heels-toes apart
• Mini-squats, two counts down with arms lifting to shoulder height in front, two
counts up with arms releasing down in front
• Mini-lunges to right side with right arm lifting out and up to shoulder height and
down and in to the side
• Repeat mini-lunges to the left
• Return to center, toe-heel-toe, feet to hip width apart
• Feet hip width apart, begin lifting to a toe tap, shifting weight to left foot
• Bending knees, shifting weight to right, tap left toe
• Continue toe taps, adding shoulder lifts, straight arms crossed in front of chest and
then overhead, four sets each arm position
• Arms reaching overhead, change to leg curls
• Continue leg curls with arms crossing at chest height
• Shoulder lifts with leg curls
• Hands to hips, leg curls moving legs together
• Straight legs extend back with opposite arm lifting and reaching forward
• Toe taps out and in, alternating sides with same arm lifting to side
• Heel taps out and in alternating sides, both arms lift to sides
• Heel taps forward and in, bicep curls
• Toe taps forward and in, alternating arm swings
• Low kicks forward and in, arm swings
• Knee lifts up and down, hands press down and pull up
• Begin walking around the room, emphasizing posture and foot placement and arms
swinging
• Vary stride from short to long steps while pumping arms
• Walk up on toes, reaching overhead
• Facing into center, side step leading right leg out and pulling left leg to right, arms
extend out to side when legs are apart and close to sides as legs come together
• Change direction to repeat side step leading left
• Continue around the room with alternating step kicks
• Forward walking fast, arms pumping
• Gradually slowing pace and returning to chair continuing to step in place
45-Degree Head Turn: Facing to right corner (off center at a 45-degree angle), lower chin
and lift, turn through center and repeat to left.
Head Turn: Facing forward, slowly turn head (keeping chin level) toward the right
shoulder as far as comfortable. Lower and lift chin. Slowly turn through front and repeat
to left.
Head Tilt: Facing forward, tilt right ear to right shoulder, return head to upright and tilt
left ear to left shoulder.
Chin Retraction: Facing forward, pull the head straight back without tucking chin and
release to center.
Shoulder Roll: Hold arms at side, elbows straight (not locked), and palms facing inward.
Lift shoulders up towards ears, rotate back and release down. Reverse direction back up
down.
Shoulder Shrug: Position arms and hands as for the Shoulder Roll. Lift shoulders up to
ears, keeping elbows straight, and lower.
Shoulder Blade Squeeze: Extend arms straight forward from shoulders, palms down
holding a Dynaband thumb to thumb distance apart. Bending elbows, pull hands back to
shoulders, keeping elbows at shoulder height until shoulder blades squeeze together. Push
arms forward to start position.
Shoulder Pull (back and down): Start same as above, pulling hands to shoulders, elbows
high and behind back, then lower arms to sides, push hands out and up to start position.
Chest Press and Fly: Position the Dynaband across the upper back and under arms,
holding ends in your hands at armpit level. Arms extend forward, out and around to sides,
elbows pulling back. Bring hands in to shoulders. Move in a smooth, circular pattern.
Reverse the circle starting with hands at shoulder, extending arms out to sides, around to
front and in.
Chest Press (slant): Sit at the front half of chair. Position the Dynaband as in the Chest
Press and Fly and lean back holding a ball behind the shoulder blades. Extend arms
forward and release back to chest.
Horizontal Arm Pull: Grip the Dynaband with palms up in front of the body. Hold hands
chest high, shoulder width apart with elbows bent. Open arms to side, keeping elbows
flexed. Squeeze shoulder blades together. Slowly release arms to front.
Bow and Arrow: Wrap one end of Dynaband around each hand and extend one arm in
front of body, shoulder height. Raise other arm in front of body with elbow bent and
pointing back. Pull arm backwards leading with elbow until fist is close to shoulder joints.
Bent Elbow Chest Fly: Hold arms out to side from shoulder with elbows at 90 degree
angle, hands with weights toward ceiling. Keeping elbows at shoulder level, close arms to
front and open to side and just beyond line of shoulder to squeeze shoulder blades.
Upright Row (side): Position legs in a split stance one leg in front of the other. Stand on
one end of the Dynaband with the forward foot. Grip the other end of the band in opposite
hand with palm back. Raise elbow no higher than the shoulder, keeping upper arm parallel
to the floor. Repeat with other arm.
Upright Row (front): Extend arms down in front of body, palms with weights or
Dynaband toward thigh. Bend elbows out to side, pulling hands up to shoulder height,
straighten arms to start position. Rotate shoulders back to do upright rows behind the back.
Upright Row (back): Rotate shoulders back, arms extended down back, underhand grip
on weights or Dynaband. Bend elbows out to side, pulling hands up back as far as
possible. Extend elbows and straighten arms to start position.
High Row: Sit on a chair with one or both legs extended. Place Dynaband around the
ball(s) of one or both feet and grip each end with the hands (palms down). Pull elbows up
and back. Release slowly.
Low Row: Sit as for High Row, holding Dynaband with palms up. Keeping arms close to
side, slowly pull elbows behind back at waist level and release forward.
Front Raise: Hold Dynaband or weights with an overhand grip, hands at thighs. Keeping
elbows straight, but not locked, raise hands to shoulder level and lower.
Shoulder Side Lift with Bent Elbow: Hold weights with palms facing (handshake grip).
Arms are at side with elbows at 90 degrees, hands in front of elbows. Lift arms up/out to
shoulder level, pull elbows back to squeeze shoulder blades, release forward, and lower
arms down/in to side.
Shoulder Rotation: Grip Dynaband or weights with palms up and hold in front of body
with elbows bent at 90 degrees. Keep elbows pressed against the waist, slowly open
forearms outward, rotating the shoulders externally. Return hands to front.
Military Press: Hold a weight in each hand slightly in front of shoulders, with arms bent
to 90 degree angle, palms facing forward. Squeeze shoulder blades together, press weights
overhead as you rotate your palms inward, straightening, not locking, the arms. Lead with
elbows lowering to shoulder height.
Lat Pulldown: Hold Dynaband or weights with an overhand grip, elbows at 90 degree
angle and straight out from shoulder, hands up to ceiling Lower elbows down/in to side at
waist and up/out to start position.
Vertical Triceps Press (down): Grip one end of a Dynaband and place that hand next to
opposite shoulder. Hold the Dynaband in the middle and place other hand directly below it.
Extend bottom arm down, hold, and slowly return. Repeat working opposite arm.
Horizontal Triceps Press (forward): Wrap one end of Dynaband around hand and place
on chest. Grip other end of band 6 8 times from other hand. Raise that elbow just below
shoulder level. Press arm forward, away from body. Hold and slowly return to start
position. Repeat with opposite arm.
Overhead Triceps Press: Holding a weight in both hands, extend arms overhead. Arms
form a triangle, upper arms close to ears. Flexing at the elbows, lower weight behind head.
Extending the elbows, straighten arms to start position.
Biceps Curl: Hold weights at sides, palms facing inward. Lift weights to shoulder by
bending elbows. Keep elbows in at side. Turn palm up when lifting. Variation: Half curls
from side to waist and from waist to shoulder.
Wall Push up: Stand facing the wall with palms on wall, shoulder width apart and arms
extended. Bend elbows and lower chest toward the wall and push away.
Abdominal Contraction: Hold ball behind waist, squeeze ball while exhaling, pulling
bellybutton to backbone. Slowly release, inhale and repeat. Variation: Contract abs while
lifting one knee and rotating opposite shoulder toward it. Do not flex torso.
Torso Rotation: Sit at front half of chair. Reach across lap, placing right hand on the
outside of the left thigh. Continue to turn to the left, using right arm on the back of the
chair to help complete the rotation. Turn head to left and look behind. Return to center
and repeat turn to right. Keep abdominal muscles contracted and stay tall while turning.
Recliner: Sit at front half of chair with arms crossed at chest. Keeping back straight and
abdominal muscles contracted, lean back until shoulders almost touch chair. Return to
upright and repeat.
Side Bend: Hold arms down at side, palms facing in and holding weights. Lean toward
one side until a stretch is felt down the opposite side of the torso. Return to upright
position and lean to other side. Repeat, alternating sides.
Wall Ball Squat: Lean against the wall with a ball behind the waist, feet out from wall
18 24 inches. Rolling the ball, slowly lower to a sitting position, keeping knees over
ankles. Push slowly to upright.
Standing Squat: Stand behind a chair to use for support when needed. Move feet from
shoulder width apart to a wider stance by turning toe heel toe out to side. Bending knees,
shift body weight back toward heels and lower body as if sitting. Straighten legs and push
to standing.
Chair Stand up: Sit at front half of chair in correct postural alignment. Place hands at
side of chair seat, resting on thighs, or arms crossed at chest with hands on shoulders. Lean
forward from the hip joint. At the same time, dig the heels into the floor, straighten knees,
come to a full stand. Sit down and repeat. Variation: ―
Rock and Roll Lifts‖ - three small
rocks forward and slightly off chair seat before coming to full stand.
Seated Leg Extension: Sit at front half of chair in correct postural alignment. Keeping
knee bent, lift one foot 2-4 times off floor holding thigh slightly off seat. Straighten knee to
extend the lower leg. Bend the knee and lower the thigh to return foot to floor. Do reps
and change legs or work alternating legs. Variation: Do a leg extension and keeping knee
bent, open the leg out to side and close to center.
Forward Lunge: Standing next to a chair, position legs in a wide split stance with inside
leg (next to the chair) forward and outside leg extending back, heel lifted. Keeping torso
erect, bend both knees until front knee is over ankle and back knee points toward floor.
Tailbone points downward. Keep head up. Straighten legs to push up to standing position.
Repeat with other leg. Hold chair for support.
Hip Abduction/Adduction: Standing behind a chair for support, slide one foot out to
side, lift, and pulse for eight counts. Pull back to standing leg. Repeat with same leg or
alternate.
Hip Rotation: Stand to one side of a chair with the standing (support) leg next to the
chair, knee slightly bent. Extend outside leg forward. Keeping toes to floor, draw a half
circle out and around, extending leg to back. Pull to standing leg. Working same leg,
reverse direction, extending back, circling out, around to front and in. Change to other side
of chair to work opposite leg.
Hip Extension: Stand behind a chair for support, if needed. Extend one leg back, knee
slightly bent. Return to standing leg.
Ball Squeeze: Stand or sit holding an 8 lb. ball between knees. Squeeze/release the ball
using inner thighs.
Hamstring Curl: Stand behind chair. Flex the foot and knee, lifting heel toward glutes.
Keep bent knee in alignment with standing leg. Extend the knee lowering foot to floor. Do
reps and change to other leg or alternate.
Heel Raise: Standing behind chair or seated, feet and knees hip width apart, toes and
knees forward. Roll through the feet, lifting the heels and shifting weight to the balls/toes.
Release and press heels to floor. Do reps working both feet at the same time or alternating.
Toe Tap: Standing behind chair or seated, feet and knees hip distance apart, toes and
knees forward. Shift weight to the heels, lifting toes as high as possible then press to floor.
Tap with toes forward, out to side, and in.
Ankle ROM: Sit in or stand behind a chair. Elect one or more of the following:
a. Point/flex foot.
b. Circle foot R/L.
c. Draw figure 8’s.
d. Move foot side to side like windshield wiper.
e. Turn sole in/out.
f. Write small letters in cursive style.
Wrist: Elect one or more of the following:
a. Flex/hyperextend.
b. Circle R/L.
c. Draw figure 8’s.
d. Move side to side, thumbs toward each other/little fingers away.
Fingers: Elect one or more of the following:
a. Open/close fingers into palm of hand as if grabbing and squeezing.
b. Play the piano with fingers straight and then curved.
c. Press hands together with fingers closed, spread fingers apart and move,
palms apart, pressing finger tips against each other.
d. Curl/uncurl fingers into palm of hand.
e. Tap each finger to the thumb, keeping fingers straight for reps, then curving
fingers while tapping.
f. Flick each finger off thumb.
Stretching completes an exercise routine. During exercise, muscles adapt to a shortened
position due to repetitive contractions. Stretching ensures muscle relaxation and elongation
to a normal resting length. During this session, the stretches are incorporated into the
strength work in order to stretch muscles immediately after strengthening the muscle or
muscle group.
Posterior Shoulder: Bring one arm across the midline of the body and place hand on
opposite shoulder. Keep elbow up and parallel to the floor. Use other hand to apply gentle
pressure above the elbow and toward the body. Repeat for other side.
Biceps/Triceps: Extend one arm straight across the front of the body at chest height.
Support and increase the stretch with the other hand above or below the elbow. Repeat with
other arm.
Anterior Shoulder: Intertwine fingers behind back. Keeping elbows slightly bent, gently
push arms upward.
Shoulder and Arms: Depressing shoulders as far as possible, let arms hang at sides.
Make small circles with the arms, working from the shoulders.
Torso and Arms: Inhale and stretch arms overhead with palms coming together. Exhale
and lower arms to sides. Inhale and stretch arms overhead with tops of the hands together.
Exhale and bring arms down, cross in front of chest and reach hands around to shoulder
blades (hug yourself).
Abdominals and Obliques: Inhale and stretch arms overhead, palms facing. Exhale and
lower one arm, placing it on the thigh for support. Continue to stretch by leaning into the
thigh and reaching further overhead with the extended arm.
Figure 8: Hold a ball in front of waist or intertwine fingers, palms facing in and elbows
close to sides. Keep torso fairly straight and make a figure 8 with hands. Extend arms to
bring down toward right hip. Lift up diagonally over left shoulder, around head and
diagonally over right shoulder and down toward left hip. Repeat figure 8 in opposite
direction.
Hips: Standing with feet hip distance apart, push hips side-to-side and alternate circles in
each direction.
Quadriceps: Using a chair or wall for support, flex one leg and raise the foot to the
buttocks. Keep knees in alignment and standing leg slightly bent. Reach back and pull
heel closer to buttocks. Repeat with other leg.
Hamstrings: Extend one leg forward, heel touching to floor, foot flexed. Keep back
straight and lean chest toward the forward knee, shifting weight to back leg.
Calves: Using wall or chair as support, place one foot behind the other in a split stance.
With front knee slightly bent, back knee straight and heel down, lean hips forward,
stretching back leg. Repeat with other leg.
Soleus: Using wall or chair as support, place one foot behind the other in a split stance.
With both knees bent and heels down, lean hips forward, stretching back leg. Repeat with
other leg.
Balance work is an integral part of most exercises in the warm-up and strength training
segments of the session. For example, squats, hamstring curls, hip extension and abduction
all work muscles that need to be strong in order to maintain good balance. The session also
includes visual and kinesthetic drills that are necessary skills for maintaining balance.
Visual Exercises
• Hold head still, move eyes left/right and up/down.
• Keep eyes fixed on a focal point, move head left/right, up/down, or draw circles
with nose.
• Follow the hand with the eyes as it crosses in front moving from side to side or from
one shoulder, up in front and overhead, down and out from the opposite shoulder.
Kinesthetic Drills
• Shift weight through the feet from heel/toes and inside/outside.
• Shift weight from one leg to other, side/side and forward/back.
• Romberg: Repeat each foot position with eyes open then closed. Arm positions
options with hands holding chair, fingers playing piano on chair back, extended out to
side, down at side, crossed on chest. Four foot positions: Feet apart, feet close
together, one foot forward, tandem.
• Walk one foot directly in front of the other in balance beam fashion.
• Lean as far to side as possible, stepping out when necessary to catch yourself.
• Visualize each foot spreading wide in the shoes, like sinking into the floor, making
footprints.
Balance Exercises
• Stand next to chair to work outside leg then move to other side of chair.
• Tap toes around front, side and back.
• Tap heels front/toes back, progressing to knee lift front/leg curl back.
• Extend toe out to side, arms out to side and lift toe off floor (five point star).
• Slide foot up the inside of standing leg to calf or knee and slowly slide down.
Take some time at the end of each Session for relaxation and cool down. Using breathing
techniques, progressive relaxation, visualization and imagery or massage are effective ways
to accomplish this. Choose one routine from below to do during the last minutes of the
Session.
a. Sit comfortably in a chair with eyes closed. Begin with a deep sigh and then quietly
inhale. Concentrate on keeping breathing slow, deep, quiet and regular. Repeat for eight
breaths, open eyes and breathe normally.
b. Pay attention to your exhalation, trying to squeeze more air out of the lungs. Work on
making your exhalation as long as or slightly longer than the inhalation. Try to count
slowly to four on the inhalation, hold breath for four, and then exhale for eight counts.
c. Sit in a comfortable position, eyes closed. Take a few deep breaths. To begin, count
―
one‖ as you exhale, then ―
two‖ with the next exhalation, and so on up to five. Begin a
new cycle, counting ―
one‖ with next exhalation. Do this for five minutes.
Use this to release tension in muscles. Get into a comfortable seated position; take a series
of deep slow breaths. Focus on different parts of the body in turn, tensing a muscle and
then relaxing it. Work down the front of the body and then the back.
Sit comfortably with eyes closed. Take a few deep breaths that make you feel peaceful and
secure. Make the image bright and clear and try to hear, feel and smell the surroundings.
Can be done with partners or self massage. Give gentle shoulder and neck massages using
bread kneading technique and/or circles with thumb/fingers.
The exercises and session plans listed below are guidelines for developing Building Bones.
Modifications may be necessary depending on the general health and skill level of the
participants. Although resistance is an important part of building bone strength, correct
exercise technique and safety are the first objectives of the Building Bones course. The
course has been taught entirely without resistance equipment for beginners and/or frail
participants. It is common to modify to no resistance for certain exercises on days when
joints are painful. No resistance is used for the lower body.
During the first 2-3 weeks with a new session, exercises could be done without equipment
in order to focus on posture and correct form. Working slower and doing fewer repetitions
are additional ways to modify the session yet still meet strength needs. Also, during this
time, working on flexibility, range of motion and balance can increase the participants'
comfort level with an exercise program and give them confidence in their ability to "stick
with it."
Most of these exercises can be done seated as well as standing. Correct postural alignment
is stressed—ears over shoulders, shoulders over hips, hips over knees (soft), knees over
ankles and feet hip-distance apart, if standing. Correct seated posture has ears over
shoulders, shoulders over hips, knees and feet hip-distance apart with feet flat on the floor.
Remind participants to exhale with the exertion. Do 4-12 repetitions of each exercise. Floor
work may or may not be included in the program depending on participants’ ability and
availability of mats. A session may never progress to getting down to the floor. In the
Tucson Building Bones course, one group does floorwork one day per week, and another
group does only standing and chair work.
Exercises are done generally in the order listed on the session plans to ensure muscle
balance. For posture, more strength exercises are done for the posterior (back) than the
anterior (chest/front).
The decision to use resistance, floorwork or a specific exercise is a judgment call by the
experienced instructor. Do what the population will bear. Start slowly and progress as the
session ability/skill improves. Be conservative.
• Introduction of instructor and participants
• Introduce the course—descriptions, goals, session format, logistical information
and outcome measurement tools
• Discuss appropriate shoes and dress, drinking water, chair and equipment location
and set-up
• Clients complete health history
• Fitness Assessments
• Complete Building Bones Questionnaire
• Discuss any necessary health history information with individuals prior to session.
Repeat introductions.
• Mini-lecture I: What is Osteoporosis?
• Handouts 1 and 2: Osteoporosis Knowledge Questionnaire and
All About Osteoporosis
• Practice correct postural alignment, neutral spine and breathing techniques.
• Warm-up: 1 and 2 patterns
• Strength Exercises
Upper Body: 1, 3, 5, 6, 7, and stretch D
Lower Body: 36, 37, 39, 40, and stretches H, I, 44, 45 and stretch K
• Balance Drills: 1, 2, 3
• Cool Down
• Ball Toss Name Game
• Discuss any questions from Session 2 mini-lecture or handout
• Warm-up: 1 and 3 patterns
• Strength Exercises:
Upper Body: 1, 2, 3, 5, 6, 7, 15 and stretch D
16, 20 and stretch A
47 a and b, 48 a and b
Lower Body: 30, 36, 37 and stretch I
41, 43 and stretches H and J
46 a, b and c
• Cool-down
• Mini-lecture 2: Osteoporosis Risk Factors
• Handouts 3 and 4: Are You at Risk for Osteoporosis? and
Reduce Your Risk of Osteoporosis
• Warm-up: 3 and 4 patterns
• Strength Exercises:
Upper Body: 3, 4, 8, 11 and stretch D; 17, 18, 22, 24 and stretch A
25, 28 and stretch B; 47 c and d, 48 c and e
Lower Body: 36, 37 and stretch I; 39, 41 and stretch H
43, 44, 45 and stretches J and K; 46 a, b and f
• Balance Drills: 1, 2, 4, 5
• Cool-down
• Questions and discussion from Session 4 mini-lecture
• Warm-up: 1 and 2 patterns
• Strength Exercises:
Upper Body: 5, 6, 7 and stretch D; 11, 16, 20, 22 and stretch A
30, 31 and stretch F; 47 a and c, 48 b, d and f
Lower Body: 35, 37, 39, 41 and stretches H and I
43, 44, 45 and stretches J and K
46 a, b, f and stretch L
• Cool-down
• Ball Toss Name Game
• Mini-lecture 3: Calcium for Life
• Handouts 5 and 6: Choosing a Calcium Supplement and Increase the Calcium
in Your Diet
• Warm-up: 2 and 4 patterns
• Strength Exercises:
Upper Body: 1, 2, 8 and stretch D; 16, 17, 18, 20 and stretch A
25, 28 and stretch B; 30, 33 and stretch F
47 b and d; 48 b, c, d and f
Lower Body: 34, 36 and stretch I; 39, 40, 41 and stretch H
42, 43 and stretch J; 46 a, b, d and e
• Balance Drills: 1, 2, 3, 4, 5 and 9
• Cool-down
• Questions and discussion from Session 6
• Warm-up: 1 and 2 patterns
• Strength Exercises:
Upper Body: 3, 4, 7 and stretch D
9, 11, 16, 20 and stretch A
47 a and c, 48 b, d, e and f
Lower Body: 36, 37, 39, 41, 43 and stretches H and I
43, 44 and stretches K and L; 46 a, c and f
• Cool-down
• Mini-lecture 4: Hormones and Osteoporosis
• Handout 7: A Woman’s Special Issue: Estrogen
• Warm-up: 3 and 4 patterns
• Strength Exercises:
Upper Body: 5, 6, 8 and stretch D
12, 15, 17, 18 and stretch A
30, 31 and stretch F
47 b and c; 48 b, c and e
Lower Body: 34, 36, 38 and stretch I
40, 41, 42 and stretches H and J; 46 a, b, d and e
• Balance Drills: 6 and 9
• Cool-down
• Questions and discussion on mini-lecture from Session 8
• Warm-up: 2 and 4 patterns
• Strength Exercises:
Upper Body: 1, 2, 7, 11 and stretch D
16, 18, 20, 24 and stretch A
30, 32 and stretch F; 47 a and b; 48 c, e and f
Lower Body: 35, 37, 38 and stretch I
39, 41, 43 and stretches H and J
44, 45 and stretches K and L; 46 a, b and f
• Cool-down
• Mini-lecture 5: Exercise and Osteoporosis
• Handout 8: Exercise for Osteoporosis: Use It or Lose It
• Warm-up: 1 and 3 patterns
• Strength Exercises:
Upper Body: 5, 6, 9, 15 and stretch D
16, 20, 22, 24 and stretch A
26, 28 and stretch B; 30, 33 and stretch F
Lower Body: 34, 37, 40, 41, 43 and stretches I and J; 46 c, d and e
• Balance Drills: 4, 5, 7, 10
• Cool-down
• Questions and discussion on mini-lecture from Session 10
• Warm-up: 1 and 4 patterns
• Strength Exercises:
Upper Body: 3, 4, 8 and stretch D
11, 13, 20, 24 and stretch A
30, 32 and stretch F; 47 a and b
Lower Body: 35, 38 and stretch I
40, 41, 43 and stretches H and J; 46 c and f
• Cool-down
• Ball Toss/Name Game: Do We Know Each Other Yet?
• Mini-lecture 6: Exercise Do’s and Don’ts
• Handout 9: Exercise Do’s and Don’ts
• Warm-up: 2 and 3 patterns
• Strength Exercises:
Upper Body: 5, 6, 8 and stretch D
10, 19, 20, 22 and stretch A
27, 28 and stretch B; 47 a and c; 48 c, d and e
Lower Body: 36, 37 and stretch I
39, 41, 42 and stretches H and J
• Balance Drills: 3, 4, 5, 10 and 11
• Cool-down
• Questions and discussion on Session 12 mini-lecture
• Warm-up: 1 and 4 patterns
• Strength Exercises:
Upper Body: 2, 4, combine 7 and 15, 10, 16, 20 and stretch A
47 a and b; 48 a, c and d
Lower Body: 36, 38 and stretch I
40, 41, 43 and stretches H and J
44, 45 and stretches K and L; 46 a, d and f
• Cool-down
• Mini-lecture 7: Vitamin D and Other Supplements
• Handout 10: Vitamin D for Osteoporosis
• Warm-up: 2 and 3 patterns
• Strength Exercises:
Upper Body: 1, 3, 6, 7 and stretch D
11, 13, combine 16 and 20, stretch A
30, 31 and stretch F; 47 a, c and d
Lower Body: 34, 37, 38 and stretch I
39, combine 41 and 43, stretches H and J
46 a, b and d
• Balance Drills: 1, 6 and 8
• Cool-down
• Questions on mini-lecture from Session 14
• Warm-up: 1 and 2 patterns
• Strength Exercises:
Upper Body: 5, 6, 10 and stretch D; 14, 17, 18 and stretch A
25, 28 and stretch B; 30, 32 and stretch F
47 c, 48 a, c, e and f
Lower Body: 36, 37 and stretch I
39, 40, 41, 42 and stretch H; 46 a, c and e
• Cool-down
• Mini-lecture 8: Diagnostic Testing
• Handout 11: Bone Density Testing
• Warm-up: 2 and 4 patterns
• Strength Exercises:
Upper Body: 2, 4, 9, 11 and stretch D
combine 7 and 14; combine 16 and 20; combine 23 and 24; stretch A
47 b and c; 48 a, b and d
Lower Body: 34, 37, 38 and stretch I
39, combine 41 and 43, stretches H and J
46 a, b and d
• Cool-down
• Questions on mini-lecture from Session 16
• Warm-up: 1 and 3 patterns
• Strength Exercises:
Upper Body: 8, 10, 11, 14 and stretch D
combine 17 and 18; 22 and stretch A
27, 28 and stretch B; 47 a and d; 48 b, c and d
Lower Body: 36, 39, 40, 42 and stretches H and I
• Balance Drills: 1, 2, 6 and 10
• Cool-down
• Mini-lecture 9: Prevent Falls and Fracture
• Handout 12: Reduce Your Risk of Falling
• Warm-up: 2 and 4 patterns
• Strength Exercises:
Upper Body: 5, 6, combine 7 and 15, stretch D
10, combine 16 and 20, combine 17 and 18; stretch A
30, 31, 32 and stretch F; 47 a, b and d
Lower Body: 35, 38 and stretch I
39, 41, 42, 43; stretches H and J
44, 45 and stretches K and L
• Cool-down
• Questions/discussion on mini-lecture from Session 18
• Warm-up: 1 and 4 patterns
• Strength Exercises:
Upper Body: combine 1 and 2, 9, combine 15 and 19
stretch A, 22, combine 23 and 24, stretch D
30, 32 and stretch F; 47 b and c
Lower Body: 34, 36 and stretch I
38, 40, 41 and stretch H; 42, 43 and stretch J
• Balance Drills: 4, 5, 7, 8, 13
• Cool-down
• Mini-lecture 10: Therapies for Osteoporosis
• Handout 13: Therapies for Osteoporosis
• Warm-up: 1 and 2 patterns
• Strength Exercises:
Upper Body: 3, 4, 7 and stretch D
10, combine 16 and 20, combine 17 and 18, stretch A
26, 28 and stretch B; 31, 32 and stretch F
47 a, c and d; 486 c, e and f
Lower Body: 34, 36, 38 and stretch I
39, combine 41 and 43, stretches H and J
46 a, c and f
• Cool-down
• Questions/discussions on Session 20 mini-lecture
• Warm-up: 3 and 4 patterns
• Strength Exercises:
Upper Body: combine 7 and 15; 11, 20, 22, 24 and stretch A
30, 31, 32 and stretch F
47 a and b; 48 a, b and d
Lower Body: 35, 37 and Stretch I
40, 41, 43 and stretches H and J
46 a and b
• Balance Drills: 6, 9, 11 and 13
• Cool-down
• Mini-lecture: Questions and Answers about Osteoporosis (review of materials)
• Warm-up: 1 and 4 patterns
• Strength Exercises:
Upper Body: 2, 4, 8 and stretch D
10, 15, 16, 21, 22 and stretch A
30, 33 and stretch F; 47 a and c
Lower Body: 34, 37, 38 and stretch I
39, 41, 43 and stretches H and J
46 c, e and f
• Cool-down
• Mini-lecture: Post-test—Repeat Handout
• Handout: Osteoporosis Knowledge Questionnaire
• Post-fitness assessments: stretches A, B, D, H, I and J
• Complete Health Curriculum Course Evaluation
• Warm-up: 4 pattern
• Strength Exercises:
Upper Body: 5, 6, 7 and stretch D
combine 16 and 20; 24 and stretch A
46 a, b and c
Lower Body: combine 35 and 39; combine 41 and 43
stretches H, I and J
• Cool-down
Osteoporosis is all about loss—loss of bone, loss of appearance, loss of independence, loss
of height, loss of function, loss of dignity. Osteoporosis affects every bone in the skeleton.
More than one million people in the United States will have fractures due to osteoporosis,
and 250,000 of these are fractures of the hip (femur) usually sustained in a fall. Fracture of
the neck of the trochanter or the femur may require surgery, even necessitate a hip joint
replacement. The women may never regain mobility, may need to enter a nursing care
facility or she may die from complications of the fracture, the surgery or even from the
enforced bed rest.
Here are the facts about osteoporosis:
• Loss of bone strength (bone fragility) is due to loss of bone minerals and loss of the
internal supporting structure of the bone. Loss of bone strength leads to increased
fractures in bones that support the body, the spine and the hip. The wrist fractures when a
woman puts out her hand to break a fall.
• Falls are the leading cause of accidental death in people over the age of 75.
• Osteoporosis in the vertebrae of the spine causes collapse fractures of the vertebral
bodies. The fracture(s) leads to pain, loss of height and a forward curvature of the spine
(―
dowager’s hump‖). Lifetime fracture risk for a 50-year-old Caucasian woman is 54 %.
One out of every three Caucasian women will have a vertebral fracture from osteoporosis.
•As bones grow longer, they grow thicker (bone mass or density). Bone density = weight
of bone divided by its size. Bone strength refers to bone mass and/or density.
There are two types of bones in the skeleton.
• Cortical or compact bone, found in the arm and leg bones, makes up 80% of the skeleton.
Cortical bone cells function, change and respond in a slower fashion than trabecular bone.
• Trabecular or cancellous bone, found largely in the spine, functions at a faster rate. Peak
bone mass for the spine occurs at age 20.
Bone has an active life cycle.
• Osteoclasts are bone cells that tear down or resorb damaged or fatigued bone creating
cavities in the bone.
• Osteoblasts form new bone, filling in the cavities.
Bone formation greater than bone resorption = bone growth.
Bone formation equal to bone resorption = maintain bone density
Bone resorption greater than bone formation = bone density loss
In osteoporosis, the tearing down or ―
resorption‖ of bone accelerates over bone formation,
and/or formation lags behind bone resorption.
Every woman must understand that osteoporosis is a disease and that every woman is at
risk for the disease. It is vital that women recognize their risk factors for development of
osteoporosis and identify those fractures they can modify. An important risk factor is
gender. Eighty percent of the 25 million people who have osteoporosis are women. Our
gender cannot be changed, but other risk factors are changeable.
One out of every two women aged 50 has a 50% lifetime risk for an osteoporosis related
fracture. One out of every three women will have a spinal (vertebral) fracture. One out of
every six women will have a fractured hip.
When women become menopausal around age 50, the ovaries stop producing the female
hormone estrogen, which is important in maintaining bone mass. Women who have female
blood relatives with osteoporosis are at greater risk for the disease. We may inherit a
tendency to build less bone.
Changeable lifestyle factors include chronic lack of physical activity, dietary habits, lack of
calcium and vitamin D and excess phosphate, protein and sodium, high caffeine and
alcohol intake and cigarette smoking.
Lifestyle factors are those risk behaviors that we can modify.
• Cigarette smoking is a behavior that increases risk for cardiac and pulmonary disease.
Cigarette smoking is toxic to the ovaries and reduces the effectiveness of estrogen. It is
also an important alterable risk factor in osteoporosis.
• Two types of estrogen are produced by the ovary and metabolized (chemically changed)
in the liver; estradiol and estrone. Estrone can be converted to 2-hydroxy-estrone, an
ineffective form of estrogen. Smoking increases the conversion of estrone to 2-hydroxyestrone, decreases the production of all estrogens and appears to destroy the eggs in the
ovary leading to early menopause. This loss of ovarian function means that women
smokers and women exposed regularly to second-hand smoke begin the accelerated
postmenopausal bone loss two years earlier.
• High amounts of caffeine increase loss of calcium in the urine. Daily intake of 400 mg
of caffeine (equal to about three five-ounce cups of coffee) apparently has no adverse
effects, if calcium intake is at least 600 mg daily. A double loss of bone occurs when
women replace consumption of milk with coffee, tea, colas and other caffeinated
beverages.
• Alcohol appears to be toxic to the bone-forming cells, the osteoblasts. There is no
evidence on the amount of alcohol consumption that is ―
safe.‖ The recommendation is,
if you drink, do so in moderation and avoid daily alcohol intake.
• Certain medications can have a negative effect on our bones. Excessive thyroid hormone
(for those who need supplements) can increase bone loss. Doctors can test to see if
the right dose is being prescribed. Steroids (prednisone, cortisone, prednisolone,
dexamethasone) decrease calcium absorption, increase calcium loss in the urine and
decrease function of bone-forming cells (osteoblasts). When less bone is made, more
bone is lost.
• Methotrexate, an anti-cancer drug, is a risk in high doses, long-term usage. Lithium, used
in manic depression, causes an increase in production of parathyroid hormones, which
causes calcium to leave bones. The anticonvulsant, Dilantin, used to stop seizures,
interferes with calcium absorption and vitamin production. GnRH agonists, used for
treatment of endometriosis and uterine fibroids, cause detectable bone loss in six months
of use. Isoniazid, used for treatment of tuberculosis, causes increased loss of calcium in
the urine.
Ninety-nine percent of calcium is found in the skeleton. Calcium is combined with
phosphate in bones to form crystalline lattice work structure (hydroxyapatite), which gives
bone its strength.
To prevent osteoporosis, women must build lots of bone from birth onward with a high
level of calcium intake and maintain an active lifestyle. Peak bone mass is reached by age
30. Women can avoid excessive bone loss, especially from the hip with adequate calcium
intake throughout the life span.
The National Institutes of Health and The National Osteoporosis Foundation recommended
daily calcium intake:
Age 25-65
1,000 mg
Over Age 65
1,500 mg
Age 25-50
1,000 mg
Over Age 50 (post-menopausal) 1,500 mg
Over Age 65
1,500 mg
The average American woman’s diet will contain about 500 mg of calcium without dairy
products. Each glass of milk adds about 300 mg of calcium and each eight ounces of plain
yogurt adds 400 mg of calcium. It is a good idea to consume low-fat or nonfat versions of
dairy products.
For women who are unable to consume dairy products, there are other food items, such as
orange juice and cereal, which have been calcium fortified.
Calcium supplements can also be taken to meet the women’s calcium needs.
Estrogen Replacement Therapy (ERT) can prevent or significantly lower postmenopausal
bone loss. ERT reduces the risk of fracture due to osteoporosis by 50%. Estrogen appears
to be important in production of substances that build bone and in preventing the release of
chemicals that stimulate bone loss.
In a bone density study of 73-year-old women, the women on ERT demonstrated spinal
bone density tests expected for 60 year olds. Another study showed a 30% decrease in the
risk for hip fracture in women on ERT. Estrogen replacement prevents bone loss anytime
the women begin therapy. The highest bone densities occur when ERT is begun at
menopause.
Bone loss in women begins at about age 30, especially from the hip. Women lose 0.5% to
1.0% of their bone mass yearly. The loss of estrogen at menopause accelerates bone loss
3% to 7% yearly for three, five or even 10 years. Rate of loss then slows to 1% per year. A
woman could lose 15% to 35% of her bone mass in those five years. A loss of 20% of bone
mass puts a woman at risk for a fracture.
Some recommend that a baseline bone density test should be done for women in their late
40s. Significant loss indicates that a woman is a good candidate for ERT to prevent
osteoporosis. Women with surgical menopause (removal of the ovaries), or early
menopause (in their 30s or 40s), may be started on ERT based on age alone.
―
The amount and strength of bone increases in response to forces on the bone from weight
bearing and resistance activities‖ (Wolff). During 14 days without contraction of muscle,
strength decreases each day about 1.3% to 5.5% of the initial strength. A study of otherwise
healthy patients placed on bed rest for disc disease showed bone losses of 0.9% per week in
the lumbar spine. Astronauts show this effect from weightlessness and inactivity. Both
processes are reversible in normal adult humans.
Disuse bone loss is due to mechanical factors: the absence of impact loading (pressure or
force) transmitted to the bone, the absence of tension applied to the bone by muscle, or
both. The bones of the legs and arms support the weight or resistance (the load) in strength
training. There is no impact loading or weight-bearing in swimming. Bone mass is
significantly correlated with muscle mass. Mechanical loading principally acts to stimulate
osteoblastic (bone-building) activity. Exercise is site-specific; to get strong legs, exercise
the legs.
A high level of activity early in life leads to high peak bone mass. The type of activity
affects bone density. A study of weight lifters (male) and ballet dancers (male and female)
showed an increased bone density in both groups as compared to healthy controls. The
dancers showed an increased bone width over the lifters and the controls even though they
were shorter and weighed less, probably a reflection of early and lifelong activity.
Maintenance of physical activity is necessary to maintain bone strength in premenopausal
women and slow bone loss later.
Benefits of exercise for the women with osteoporosis who have fractures include pain
relief, improvement in posture, muscle strength and tone, agility, balance, reduction in risk
for falls and slowing of bone loss. There are safe and beneficial exercises for woman with
fractures that improve quality of life.
Weight-bearing means the weight of your body is on your legs. Walking is weight bearing,
bicycling is weight bearing for the spine and swimming is nonweight-bearing.
Impact loading means an impact or force is transmitted to the bone. The faster you walk or
run, the greater the impact load on the bones. Jumping delivers a large impact load.
An aerobic, weight-bearing exercise program should begin slowly and build progressively
to increase in time and intensity. The time goal of three 60-minute sessions a week is more
important than speed or intensity. Walking is an excellent weight-bearing exercise
requiring only a good pair of shoes for equipment. Aerobic dance is good if you like
company when you exercise. Aerobic equipment such as treadmills and stair-steppers can
provide a weight-bearing workout.
• Strength or resistance training is an important adjunct to weight-bearing exercises.
• Site specific strengthening is necessary for the upper body and spine.
• Benefits of strength training include improved appearance, posture, confidence,
independence and upper-body strength.
Strength work can be done with adjustable weight stack machines, free weights (dumbbells
and barbells), resistance bands, balls and the free weight of the body (pushups and sit-ups).
There are a variety of workout schedules, a variety in the number and types of exercises,
and varying numbers of sets and repetitions for each exercise.
Exercises should be performed using the chest, back, upper and middle spine, arms,
abdomen, buttocks and thighs. A good exercise program for osteoporosis is one hour daily,
six days a week alternating strength and aerobic exercises. A strength training schedule is
for three days per week with no more than two days off between workout days.
Consistency and regularity help you achieve your exercise goals of building strong muscles
and bones. ―
Forty continuous days form a habit.‖ Exercise for the prevention of
osteoporosis.
A complete program to maintain bone strength and slow bone loss will include
cardiovascular conditioning, muscle strength and endurance exercises, and balance,
coordination, flexibility and agility activities. Staying active physically improves quality of
life and allows women to remain involved and independent.
Exercise safety is critical for women with significant bone loss (osteopenia) or osteoporosis
who are at greater risk for a fracture.
• Start slowly with back extension and abdominal exercises.
Add walking, muscle strength exercises and others.
Gradually add weights to your strength program.
• Walk! Walk!
Begin with short, slow walks every other day.
A good walking program to increase bone strength includes a three mph pace
for 50 minutes, five days weekly (2.5 miles).
Start at a one mph pace for five minutes two or three days weekly.
Walking benefits heart and lung function and improves leg strength to decrease
risk of falls.
• Pump iron! Functional strength training is weight lifting, using resistance bands or using
your body weight (standing up from a chair). Strengthen bones and muscles to increase
functional abilities. Target muscles: gluteals (hip), quadriceps (thighs), trapezius/
rhomboids (upper back), erector spinae (vertebral), biceps/ triceps (upper arm), deltoids
(shoulder), forearm flexors/ extensors (wrist).
• On your toes! Perform exercises to improve balance, coordination and agility.
• Anti-Dowager’s Hump! Spinal extension exercises are those that arch the back.
These exercises can be done sitting or standing, resistance is not necessary. Safe exercises
that can reduce pain, strengthen supporting muscles of the spine, lessen back fatigue and
correct a stooped posture.
• No unsupported forward bending of upper body (sit-ups, crunches, toe touches or rowing
machines). Increases spinal fracture risk.
• No jumping, running or high impact aerobics. Impact loading of the spine increases
fracture risk.
• No activities or exercises that increase risks for falling: step aerobics, trampolines or
jumping rope. Slippery floors, icy sidewalks are also risky.
• No abduction/adduction (moving leg out to the side and back in) of leg against resistance
or weight.
Vitamins are organic substances, used in the body as catalysts or enzymes for many critical
reactions. Some vitamins are very important in osteoporosis prevention and treatment.
Vitamin D: The skin produces pre-Vitamin D when exposed to the sun (ultraviolet
radiation). Another source of pre-Vitamin D is food. Pre-Vitamin D is altered in the liver
and the kidney to the usable Vitamin D. Vitamin D increases the absorption of calcium in
the intestinal tract.
Fifteen minutes of daily skin exposure to the sun is necessary to form sufficient preVitamin D. Avoid the intense sun from 11:00 AM to 4:00 PM. Sun block prevents
formation of pre-Vitamin D. As we age, our skin may need more sun time. Vitamin D
deficiency may occur with winter’s shorter sun time, with skin cancer cautions in hot,
sunny areas and in people who are housebound.
In liver and kidney diseases and with increasing age (past 65 years), the ability to make
Vitamin D is reduced or halted. Anti-seizure medications may increase elimination of
Vitamin D.
Vitamin D is critical to reduce fracture risk. Women on a daily intake of 1,200 mg of
calcium and 800 units of Vitamin D showed 43% fewer hip fractures over women not
taking supplements.
U.S. RDA is 400 units (some recommend 600 units for older adults). Food sources are
fish, liver and eggs, milk fortified with vitamin D (one cup = 100 units), multivitamin and
some calcium supplements. It is not necessary to take calcium and Vitamin D together,
although both are needed for bone production. Vitamin D is stored in the body, and
excessive amounts raise blood calcium levels which can lead to nausea, vomiting, seizures
and death.
Other vitamins and minerals are important for a healthy, well-balanced diet and may affect
bones:
• Vitamin B12: RDA = 2.0 micrograms. Food sources are muscle meats, eggs
(1 egg = 0.77 micrograms) and dairy products. It may be important for the cells that form
new bone (osteoblasts). Supplementation for osteoporosis is not generally recommended.
• Vitamin K: RDA = Young girls: 45-55 micrograms, Women: 60-65 micrograms.
Food (1 cup of lettuce = 95 micrograms). Sources are green, leafy vegetables (1 cup of
lettuce = 95 micrograms). It may be important for new bone formation. Supplementation
for osteoporosis is not generally recommended.
• Vitamin C: RDA = Girls: 50 mg, women: 60 mg. Food sources are tomatoes, salad
greens, peppers and citrus fruits. (1 orange = 60 mg) Important for collagen production,
which combined with minerals, gives bone its strength. Supplementation for osteoporosis
is not generally recommended.
• Vitamin A ―
beta-carotene‖: RDA = Women: 8,000 units. Food sources are green and
yellow vegetables (2/3 cup cooked broccoli = 2,500 units), milk, butter and cheese.
While critical to normal bone growth, excessive vitamin A is toxic. Supplementation for
osteoporosis is not generally recommended.
• Magnesium: RDA = Girls: 280-300 mg. Women 280 mg. Food sources are whole grains
(1 cup cooked pasta = 29 mg) and green, leafy vegetables. Osteoporosis is seen with
magnesium deficiency in diseases such as alcoholism and malnourishment, and with the
thiazide diuretics, taken for high blood pressure and fluid retention. Connection is by
association, rather than cause-effect. Excess magnesium can cause diarrhea (laxative
―
milk of magnesia‖). Supplementation for osteoporosis is not recommended.
• Zinc: RDA = 12 mg. Small amounts are found in many foods. Zinc deficiency is
associated with stunted growth and osteoporosis, and high levels in the urine are a marker
for bone loss. Recommended to meet the RDA with adequate nutrition or take a
multivitamin/mineral supplement.
Small amounts needed. Toxic amounts are 2-3 times normal range.
• Manganese: RDA= none (desirable range = 2.5 –6.0 mg). Found in many different food
types. While critical to bone and cartilage development, there is no known link to
osteoporosis. Excess amounts affect the nervous system. Supplementation for
osteoporosis is generally not recommended.
• Boron: RDA = none (customary intake 1-3 mg). Food sources are fruits and vegetables.
Its importance to osteoporosis, if any, is not known. Excess boron is toxic.
Supplementation for osteoporosis is not generally recommended.
• Copper: RDA = none (range 2-3 mg). Food sources are white meats, other meats and
water. Copper deficiency is not a proven cause of osteoporosis. Excess copper is
associated with bone abnormalities. Supplementation for osteoporosis is not generally
recommended.
• Silicon: RDA = none found in many different foods. A link to osteoporosis is not known.
Supplementation for osteoporosis is not generally recommended.
• Fluoride: RDA = none. (adult range = 1.5 –4.0 mg). Food sources are seafood, tea and
water. Fluoride is commonly added to drinking water to prevent tooth decay. Fluoride can
cause marked increase in spinal bone density, but fractures still persist. Bone quality
produced is poor. Excess fluoride is harmful. Supplementation for osteoporosis is not
generally recommended.
Bone density refers to the quantity of a mineral found in a certain amount of bone. A bone
mineral density (BMD) of 1.0 g/cm2 means you have one gram of that mineral in every
square centimeter of bone.
• Conventional X-ray—Unable to accurately demonstrate a difference until there is a
30% loss of bone density. Unable to predict fracture risk.
• Risk Factors Questionnaires—Useful for identifying and correcting your risks.
Unable to predict bone density or fracture risk.
• Single Photon Absorptiometry (SPA)—Can only measure bone density of the wrist and
heel. Unable to predict fracture risk for hip or spine.
• Dual Photon Absorptiometry (DPA)—Able to measure hip, spine and whole body bone
density. Able to predict fracture risk, not reliable in detecting small changes in bone
density over time. Uses radioactive isotopes, radiation exposure on spine test is 1-1/2 of a
front and side view chest x-ray. Whole body study = 60 minutes.
• Dual Energy X-ray Absorptiometry (DEXA)—All areas of skeleton and total body can
be measured. Accurately predicts fracture risk and measures small changes over time. No
radioactive isotopes, radiation exposure on spine test is 1/30 of a front and side view chest
x-ray. Whole body study = 10 minutes. Preferred method for bone density testing.
• Bone Mineral Density (BMD) from area measured.
• Risk for fracture due to osteoporosis.
• Premenopausal baseline testing in the late 40s. If a woman demonstrates significant
fracture risk, estrogen could be prescribed to prevent osteoporosis.
• BMD testing can determine if the dose of estrogen is sufficient to prevent bone loss.
• Suggested for people taking cortisone or other high risk medications.
• Recommended sites for testing are the spine and hip.
Falls are the sixth leading cause of death and the leading cause of injury death in older
adults. In people over age 65, 20%-30% will have a fall this year. Over the age of 80, that
number rises to 50%. Serious injury or death occurs in 10% of the falls. Hip, pelvic and
wrist fractures due to osteoporosis are often the result of preventable falls.
Muscle weakness, poor coordination, dizziness/lightheadedness on standing up, failing
eyesight or bi-and tri-focal eyeglasses, environmental hazards and side effects related to
medications are major contributors to falls.
Most falls occur in the home. The bathroom and the kitchen are most often the scene of
accidental falls. Make inexpensive changes to alter risk factors.
• Prevent slipping in the bathtub or shower by installing grab bars for entry/exit to the tub
and a bar on back wall to assist in position changes.
• Place non-skid mats or adhesive strips on bottoms of tub or shower.
• Bath chairs or benches in tub or shower help avoid hazards of sitting down/standing up
in the tub or standing for a prolonged time.
• Use transfer benches to get in and out of the tub while remaining seated.
• Do not use bath oils, water softeners and cleaning agents that make surfaces slippery.
Apply oils and lotions after bathing.
• Remove small area rugs; use non-skid bath mats.
• Common night time falls can be avoided by placing light sensor (automatic turn-on) night
lights in bedroom, bath and hallways.
• Keep traffic patterns clear of objects that contribute to falls: small tables, small area rugs
and loose items on the floor.
• Platform, ―sc
uff-type‖ and fabric sole slippers contribute to falls. Use moccasin type
slippers with a non-skid sole.
• In the kitchen, use a non-slippery floor cleaner, not wax.
• Wipe up spills.
• Stairs/steps should have sturdy handrails and be well lit. Repair cracks or irregularities
in walkways and steps.
• Have regular vision checks; use eyeglasses at night if needed. See your doctor if you note
any dizziness on standing. Depth perception is altered by age-related changes in vision
and bi-and tri-focal glasses.
• Use handrails on stairs. Use assistive devices (canes and walkers) when appropriate.
• Certain medications that can increase the risk of falls are long-acting sleeping pills,
tranquilizers, antidepressants and drugs to treat mental illnesses. Discuss use and dosage
with your physician, but do not stop taking them on your own. Regular exercise and
strength training can remedy muscle weakness, poor coordination and lack of agility at
any age.
The following are the most recent therapies prescribed for osteoporosis:
Adequate intake of both of these is important, especially after a diagnosis of osteoporosis.
Calcium intake should be 1,500 mg daily and Vitamin D intake should be 400-600 units
daily.
Estrogen replacement therapy is usually used at menopause to prevent bone loss. But it is
also effective as a treatment and acts to decrease bone breakdown, increase bone density
and lower fracture risk. Estrogen is usually taken in combination with progesterone for
women who still have their uterus to prevent uterine cancer.
Fosemax)
This medication bonds to calcium in the bone and helps slow the breakdown of bone. It is
taken daily on an empty stomach with water — at least eight ounces. You must remain
upright (sitting or standing) for 30 minutes after taking the drug to prevent reflux into the
esophagus and irritation.
This new medication has estrogen-like effects on the bone without the side effects on the
female reproductive organs. It works to decrease bone breakdown. Evista is taken daily in
tablet form, if approved for prevention of osteoporosis after menopause. It can cause
increased hot flashes. Side effects of long-term use are being evaluated.
A hormone which acts to slow bone loss, it was one of the first treatments for osteoporosis.
It is available in a nasal spray or injectable form. This treatment is less effective than the
newer therapies and now is rarely used.
Answer the following questions to find out how much you know about osteoporosis. For
each statement, check true or false. Then check your knowledge with the answer sheet on
the next page.
1. False. Osteoporosis is common, but not a natural part of aging. There are many actions
you can take to prevent osteoporosis or to maintain bone strength, such as exercising and
getting enough calcium and Vitamin D in your diet.
2. True. All of the bones are affected from the toes to the jaw bone. But weight bearing
bone such as the hip and spine are especially important, because fractures of these bones
are painful and debilitating.
3. False. We can’t feel the changes caused by this bone-thinning disease. For some, loss of
height or even a hip fracture is the first sign.
4. True. Dietary calcium comes mostly from dairy products, but supplements are often
required to ensure adequate intake.
5. False. Weight-bearing and strength exercises are necessary for women of all ages and
help to improve bone strength even in later life.
6. True. Estrogen plays an important role in maintaining bone strength, and after
menopause, bones lose calcium. Men continue to make the male hormones after mid-life
so they are less likely to get osteoporosis.
7. True. It is important to prevent falls so that you can avoid fractures. Make sure your
home is free of hazards, especially the bathroom. Get your vision checked and get
regular exercise to improve your strength and balance.
8. True. The hip and spine are two of the weight-bearing bones most affected by
osteoporosis. Their status reflects bone strength in all the bones, so they are often tested
for bone density to help diagnose osteoporosis.
9. False. There are several medications that can help prevent further bone loss and can be
prescribed by a physician.
10. True. Estrogen replacement therapy increases bone strength and decreases the risk
of fractures.
• The key to preventing osteoporosis is knowledge about how bones function and what we
can do to make our bones stronger.
brittle bones‖ can affect all of your bones. There is a loss of the minerals
• Osteoporosis or ―
that form the bones and a loss of the supporting structure inside the bones. When the loss
of bone is excessive, osteoporosis occurs. There are often no warning signs until a
fracture or loss of height is noticed.
• Bone is constantly changing, with old bone removed and replaced by new bone. As bones
grow longer, they grow heavier (bone density) and thicker (bone mass). Bone strength
refers to both bone mass and bone density. We reach our peak bone density at about age
30.
• As we age, the tearing down or ―
resorption‖ of bone accelerates over bone formation, and
we begin to lose bone strength. Loss of estrogen at menopause causes a more rapid loss of
bone strength for women, especially in the first five years after menopause.
• Loss of bone strength leads to increased risk of fractures, especially in the spine and hip.
Osteoporosis leads to 1.5 million fractures each year, including 300,000 hip fractures.
• If you are at risk or have signs of osteoporosis, tests can be done to determine the strength
and density of your bones. The loss of bone strength can be prevented or treated, and the
younger you start, the better. But at any age you can decrease bone loss and even increase
bone strength by exercising, eating right and seeking appropriate medical treatment.
Encourage your daughters and granddaughters to start early!
• A good resource if you have osteoporosis or want more information is the National
Osteoporosis Foundation, 1232 22nd Street NW, Washington, D.C., 20037-1292, phone
(202) 223-2226, www.nof.org.
Check all the items that apply to you.
How many risk factors do you have for osteoporosis?
It is important to note that not all risk factors for osteoporosis can be changed. If you have
risk factors you can't change, like a family history of the disease, then it becomes even
more important for you to work on those risk factors you can change. The more risk factors
you have, the greater your risk of getting osteoporosis. The key things you can do to lower
your risk of osteoporosis include the following:
• Get enough calcium, either through your diet or by taking supplements. Women after
menopause need l,500 mg of calcium each day.
• Get enough Vitamin D in your diet or by taking supplements. Older adults need 400-600
units of Vitamin D each day.
• Exercise regularly. Physical activity, especially weight-bearing activities like walking,
help build bone and prevent bone loss.
• Move toward a healthier lifestyle. Avoid smoking and excess alcohol or caffeine.
• Explore whether estrogen replacement therapy (HRT) is right for you after menopause.
Estrogen slows the bone loss that occurs after menopause.
• Discuss your risk factors for osteoporosis with your doctor to determine if you need
further evaluation or treatment.
It can be difficult getting enough calcium in your diet, especially if you don’t use dairy
products. Keep a diary of your diet for a week and determine how much calcium you take
in on a daily basis. Supplement your diet with calcium tablets or other nutritional
supplements as needed.
The following describes the common supplements. It is important to note that some
calcium products are not usually recommended because they are not absorbed well, are
difficult to dissolve so that your body can absorb the calcium or don't provide enough
calcium to be helpful. There are new products available all the time. Check with your
doctor or pharmacist.
Eating foods rich in calcium can help you increase the calcium in your diet. The following
table shows the amount of calcium provided by different foods. Each of the food groups is
listed separately. Individual foods are put into categories by the amount of calcium they
provide, high, medium or low.
• Women begin to lose bone mass after the age of 30 at a rate of a little less than 1% per
year.
• The first five years after menopause, this bone loss increases to about 5% per year. A
woman could lose 15-35% of her bone mass during this time.
• Women who take estrogen at menopause significantly reduce loss of bone mass and
decrease their risk of fractures.
• Estrogen can be prescribed at the time of menopause or at any age to help slow down
bone loss.
The decision to take estrogen replacement therapy (ERT) or hormone replacement
therapy (HRT) involves thinking about more than just preventing osteoporosis. There are
other potential benefits and some possible risks to taking estrogen.
• Prevention of osteoporosis and loss of bone strength
• Prevention of heart disease and stroke, lower LDL cholesterol
• Improvement in the symptoms of menopause (hot flashes, sleep problems, vaginal
dryness, changes in mood)
• Possible prevention of Alzheimer’s disease, colon cancer, macular degeneration and
others
• Side effects such as headache, vaginal bleeding, fluid retention, breast tenderness
• The risk of breast cancer is not clear, but most agree that there may be a slight increase
in risk with long-term use, such as more than five to ten years.
• Slight increase in risk for blood clots
• Increased risk of uterine cancer if not taken with progesterone. (Estrogen is usually
prescribed in some combination with progesterone to avoid this risk)
It is important to identify your personal risks and benefits before deciding whether estrogen
replacement therapy is right for you. For example, if you have a family history of heart
disease and osteoporosis, taking estrogen may be important for you. If you have a family
history of breast cancer, then the risks may be more important.
Discuss estrogen replacement therapy with your doctor to determine the right approach
for you.
Estrogen comes in a variety of preparations, but not all of them provide an adequate dose to
treat or prevent osteoporosis. The following describes the different types of preparations
that are available:
Being physically active and using your muscles and bones are an important part of
maintaining bone strength. Contraction of the muscles and the pull they place on the bones
helps increase bone formation. Gravity also helps by adding a stress to the bones as we
work to stay upright. People who exercise a lot in early life, such as athletes, develop very
strong bones.
When no pressure or force is applied to the bones they become thinner and weaker.
Astronauts lose bone during long space flights because of the loss of gravity and decreased
pull on the bones. With a sedentary lifestyle, disuse results in thinner, weaker bones or
―
disuse bone loss.‖
Exercise works to counter bone weakness and build bone strength. There are two kinds of
exercises that are helpful:
Weight-bearing exercises place the weight of your body on the bones. Examples are
standing and walking. Swimming is not a weight bearing exercise because you become
weightless.
Impact-loading exercises apply pressure or force on the bones to strengthen them.
Walking is a low impact activity. Running and jumping are high impact activities because
speed increases the impact.
To improve or maintain bone strength, an exercise program will include both weightbearing activities and impact-loading exercises. A weight-bearing portion, such as walking
or low-impact aerobics, is appropriate. Strength training adds the exercise of individual
muscle groups using weights or resistance techniques. Strength training makes use of
weight machines, dumbbells and barbells, resistance bands, balls and the free weight of the
body.
Exercise provides these benefits for women with osteoporosis and fractures:
• improved posture and balance, muscle strength and flexibility
• reduced risk for falling
• slowing of bone loss
• improved appearance and confidence
Here are important things to do as you start a regular program of exercise:
Start Slow! Begin with simple back extension exercises. Gradually add walking, muscle
strengthening and other exercises as you get stronger. You may want to consult an exercise
professional to design and monitor the progression of your program.
Walk! Walk! Begin with short, slow walks every other day. Progress to longer walks, then
walk more days. A good walking program to increase bone strength is a 3 mph pace for 50
minutes (or 2.5 miles), 5 days per week. You may start at a 1 mph pace for 5 minutes 2 or 3
days weekly. Remember that walking also benefits your heart and lungs and improves leg
strength to decrease the risk of falls.
Pump Iron! Strength-training exercises include weight lifting, using resistance bands or
using your bodyweight, such as standing up from a chair. Target muscles include: the
gluteals (hip), quadriceps (thighs), trapezius and rhomboids (upper back), erector spinae
(mid-back), triceps and biceps (upper arm), deltoids (shoulder), and forearm flexors and
extensors (wrist).
On Your Toes! Perform exercises that improve balance, coordination and agility.
Anti-Dowager’s Hump! Spinal extension exercises are those that cause the back to gently
arch. These exercises can be done sitting or standing, and no resistance is needed. They can
reduce pain, strengthen muscles that support the spine, lessen back fatigue and decrease
stooped posture.
If you have osteoporosis, there are some exercises that are not safe for you:
No unsupported forward bending of the upper body. Sit ups, crunches, toe touches or
rowing machine will cause this movement. These can increase the risk of spinal fractures.
No high impact aerobics, jumping or running. Heavy impact loading can cause fractures.
No activities or exercises that increase your risk of falling. Exercises such as step aerobics,
difficult steps, trampolines, jumping rope can increase the risk of falling.
No moving the leg out to the side and back (abduction and adduction of the leg) against
extreme resistance or weights.
Vitamins are organic substances used in the body as catalysts or enzymes for many critical
reactions. Vitamin D is very important in osteoporosis prevention and treatment.
• is produced when the skin is exposed to the sun (ultraviolet radiation)
• increases the absorption of calcium from the intestinal tract
• is important in bone formation
• Fifteen minutes of mid-day sun exposure each day during the summer months is all that is
needed to get adequate amounts of Vitamin D.
• Sun block prevents rays from getting through the skin. If you are concerned about getting
too much sun, avoid being out during the hours of 10 a.m. to 4 p.m., but lengthen your
exposures to 30 minutes.
• Vitamin D deficiency can occur in the winter, in people who are housebound and even
among people in sunny areas who avoid the sun.
• The ability to make Vitamin D is reduced in some kidney and liver diseases and with
some anti-seizure medications.
• As we get older, our ability to make Vitamin D from sunlight decreases and supplements
may be needed to get the required amounts of Vitamin D.
• Your doctor can check a Vitamin D level to see if you have a deficiency and discuss the
right amount of Vitamin D for you.
The U.S.R.D.A. (recommended daily allowance) for Vitamin D is 400 units per day, and
research indicates that 600 units may be needed by older adults each day. Food sources
include fortified dairy products, fish, liver and eggs. One cup of milk fortified with Vitamin
D provides 100 units of Vitamin D. At this time, a supplement of 400-600 units of Vitamin
D daily is recommended for women over 60, for those unable to get sun exposure or those
with limited dietary resources. It is not necessary to take calcium and Vitamin D together.
Bone Density Tests can help determine whether or not you have osteoporosis, or if you are
developing osteoporosis. A bone density test is a special kind of X-ray that can look at the
bone mineral content and thickness of the bone.
• Bone density tests are done using a procedure called Dual Energy X-ray Absoptiometry
(DEXA). This involves an X-ray of the spine and hip, done while lying on an X-ray table.
The radiation exposure is very small and it takes about 15 minutes.
• The results of your bone density test are compared to the results from normal individuals
of your age and size, and to younger individuals. Low readings indicate that you have less
than expected bone mineral content which signals osteoporosis.
• The amount of bone loss you have can help predict your risk of bone fractures in the
future, and the rate of bone loss. Your doctor uses the results to help plan treatment, and
to monitor the effects of treatment. Improvement in bone density or avoiding further loss
of bone can be detected.
• Portable bone density machines are now available that can test your heel or finger and
help detect osteoporosis. These tests are very easy and less expensive than the regular
tests, and may be more available. But the portable tests are not as accurate as the regular
bone density test and may be unable to detect changes in bone density. The regular test
also check the density of the bones that are most likely to get a fracture—the spine and
hips. Your doctor may order a regular bone density test, even if you have had a portable
test.
• Talk to your doctor to see if you should have a bone density test, and if you will need to
have tests done in the future to monitor your bone density.
Falls occur in about 30% of older adults each year. They are the major cause of fractures in
osteoporosis. There are many things you can do to decrease your risk of falls. Here are
some to consider:
• Install grab bars in the bathtub or shower for entry and exit. Install grab bars on the back
wall to assist in changing positions.
• If you are unsteady or weak, use a bath chair or transfer bench to avoid the hazards of tub
entry, sitting down or standing up in the tub.
• Install sturdy handrails on stairs and steps.
• Use a cane or walker, if needed, to prevent a fall.
• Repair cracks or irregularities in walkways and steps.
• Place non-skid mats or adhesive strips in the bottom of the tub or shower.
• Avoid bath oils or water softeners that make surfaces slippery.
• Remove small area or throw rugs.
• Keep areas well-lit, especially stairs.
• Use nightlights in hallways and bathrooms.
• Keep traffic areas clear of clutter or phone lines.
• Wipe up spills immediately.
• Make sure your vision is checked regularly and glasses updated.
• Let your doctor know if you have any falls, lose your balance or experience dizziness
when you stand up. You should get a check-up and have your medications checked.
• Be aware of medications that increase the risk of falling, especially sleeping pills,
tranquilizers and sedatives.
• Wear supportive shoes with soles that don't slide or stick. Avoid heels and slippers
without backs.
• Get regular exercise to improve your muscle strength, flexibility and balance.
The best treatment is prevention! It is impossible to make up for most bone density and
mineral content that is lost. New drugs are being studied, so watch the news and check with
your doctor for new developments. But there are medications that are used in the treatment
of osteoporosis that can decrease or stop bone loss and may provide some benefits:
• Calcium is the mineral in bone. Older women should get a calcium intake of 1,500 mg
daily.
• Vitamin D helps the body absorb and use calcium and intake should be 400-600 units
daily.
• Estrogen replacement therapy used at menopause can help prevent bone loss. But it is
also effective as a treatment and acts to decrease bone breakdown, increase bone density
and lower fracture risk. Estrogen is usually taken daily as a tablet and is prescribed in
some combination with progesterone for women who still have their uterus to prevent
uterine cancer.
• Fosemax (Alendronate) and Actonel (Resindronate Sodium). These medications
bonds to calcium in the bone and help slow the breakdown of bone. They are taken daily
on an empty stomach with at least 8 ounces of water—about a half hour before breakfast.
You must remain upright (sitting or standing) for 30 minutes after taking this drug to
prevent reflux into the esophagus and irritation.
• Evista (Raloxifene) has estrogen-like effects on the bone without side effects on the
female reproductive organs. It works to decrease bone breakdown. Evista is taken daily in
tablet form, if approved for prevention of osteoporosis after menopause. It can cause
increased hot flashes. Side effects of long-term use are being studied.
• Calcitonin is a hormone which acts to slow bone loss, it was one of the first treatments
for osteoporosis. It is available in a nasal spray or injectable form. This treatment is less
effective than the newer medications above and is now rarely used.
• Parathyroid Hormone is being studied as a new treatment for osteoporosis. Studies have
been promising and parathyroid hormone may be approved soon. Parathyroid hormone
may work better than other agents at improving bone mass.
Please return this form to the instructor.
Thank you!