Understanding Bone Mineral Density Assessment

Dr. Dustin Jones // #GeriOnICE // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Dustin Jones discusses helping patients better understand their osteoporosis diagnosis, including learning to read a DEXA scan. Dustin also shares tips on discussing prognosis with patients as well as using the data supporting their osteoporosis diagnosis to inform your treatment choices & plan of care development.

Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog.

If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

EPISODE TRANSCRIPTION

INTRODUCTIONHey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the PT on ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane, an online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane, or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account. DUSTIN JONESWhat's up team? Dustin Jones here. You are listening to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. Today we're talking about osteoporosis diagnosis, prognosis, and treatment. This is a big topic that so many of the folks, older adults that we work with, they will receive this diagnosis or have this discussed with them. And a lot of times it's not given a lot of context or they don't have full understanding of what this really means for them and what they can do about it. Most importantly, what they can do about it. All right, so let's get into this. OSTEOPOROSIS: DIAGNOSIS We'll start with the diagnosis piece, just really defining what is osteoporosis and then spend a little bit more time on the prognosis side of things and the treatment because I feel like that's where we have a lot of opportunity to really serve our folks well. So osteoporosis, we're going to review, go all the way back to your formal training when you learn some of these numbers. that we may have forgotten, all right? So when someone is, when that conversation of bone mineral density starts to come into play, usually it's for postmenopausal women or males over 50 years old, start to look at bone mineral density. And the way that we can measure, objectively measure bone mineral density is through a DEXA scan. You'll see that D-X-A or D-E-X-A, that's Dual Energy X-Ray Absorbed Geometry or DEXA. This is the reason why everyone calls it that. So you're basically looking at bone mineral density. And if for individuals that are over that kind of 65 year range, you're going to get a score. That score is going to be a T score. And so we're taking the measurement of the minerals in the bone in a certain area and comparing that to same sex and race norms for a younger population. So we're comparing it to a younger cohort, and that's where you'll get those T-scores. And so based on those T-scores, you will get maybe something from 0 to negative 1, and that is considered to be normal and healthy. Then that negative 1 to negative 2.5 is that osteopenic range or osteopenia which means the bones are a little bit weaker but not full-blown osteoporosis just yet and then below negative 2.5 and below they will receive that osteoporosis diagnosis. Typically, along with the DEXA scan, a physician is doing a FRAX screen. This measures the 10-year risk of having a fracture. There's some different lifestyle questions and it'll basically spit out a percentage of likelihood that that individual is going to have a fracture within the next 10 years. And so those two pieces of information really formulate the, or someone giving a diagnosis, but then also the treatment that follows. And then based on those T-score readings, as well as the FRAC score, the pathways are typically, there's gonna be some pharmacology involved, right? Whether we're preventing bone resorption or really encouraging more bone formation and remodeling. And then they're typically going to give some blanket generic recommendation of exercise of weight bearing exercise. All right. Now, the tough part about this diagnosis, it can come from a whole host of different providers. So you can see primary care physicians, you know, kind of leading the charge of, you know, looking into bone mineral density. Internists can as well. Orthopedic physicians can as well. And so there will be different doctors that will be kind of looking into bone mineral density. And then they will often refer out to someone like an endocrinologist, for example, for further treatment and so there's a lot of people kind of involved talking about this and what at least I have seen is that this has been a topic that has been brought up and a lot of fear has been revolving around this topic but not a ton of guidance of what it really means day to day to really influence bone mineral density beyond taking that pill and you know quote-unquote weight-bearing activities. I've just worked with so many people that did not understand that diagnosis and what it actually meant. So just understand that. I'm not saying that always happens, but in a lot of the folks that I work with, that is typically the case. OSTEOPOROSIS: DIAGNOSIS So they're given this diagnosis and now let's talk about the prognosis. In particular, what I want to speak to is the opportunity to really dive in to the DEXA scan that our patients receive. And I'm not saying it is our place to kind of give a medical prognosis per se. Well, I guess when I'm saying prognosis is what can they expect going forward and to give them context of that diagnosis. So I'm mainly working the context of fitness now at Stronger Life in Lexington, Kentucky, and it's a gym for folks only over 55. And we're about four years old now, and so over the past four years, we've had a lot of members that have had at least a couple DEXA scans at this point. And so I'll put a field out for folks to send me some of their DEXA scans, and this is something that, these are conversations I'll typically have with folks anyway, once they get their DEXA scan. This is something I want you all to do. I want you to ask some of your folks that have osteoporosis on their, you know, their chart, their diagnosis list. Say, Hey, can I see your DEXA scan? Or, you know, if you're in a medical system, look up their DEXA scan, because it's really interesting. And you start to look at a lot of these reports and you'll have some of them that are more kind of narrative based, um, that, you know, are basically just several paragraphs kind of outlining, um, you know, what to expect, what they found, something more along the lines of, a bunch of words if you're not watching I'm just holding up some of these DEXA scans but more narrative but then a lot of them will actually have graphs of T-scores when they had that DEXA scan and where. So the most common areas are going to be the lumbar spine, the neck of both femurs, bilateral femurs, and then they'll kind of zoom out a little bit and look at the total hip as well. And so get those DEXA scans and look at some of those numbers. And when you start to look, what you're often going to find is variation amongst the different sites. So you can have individuals that may have that negative below negative 2.5, negative 2.5 or below, let's say at the neck of the left femur, for example. And then the neck of the right femur may be negative 1.7, osteopenic. The lumbar spine may be negative 1.5, for example, osteopenic. And so technically that person has osteoporosis on the left, on the left side, right? The right and the lumbar spine does not have osteoporosis, osteopenic, still a concern, right? But not as bad as that left side. That message is often missed by many of our patients. Now, I believe they're getting that message, you know, when they are getting these reports and having conversations with some of the physicians, but they're probably getting all kinds of recommendations. They're getting that diagnosed and all kinds of things that, you know, we only may only hear half of what is actually being said. But a lot of folks I work with, they will receive that diagnosis of osteoporosis that in reality is only in their lumbar spine, for example. and they will take that and own it as if every single bone in their body is brittle and about to combust under any type of pressure or load. They embrace that diagnosis as it's this global systemic osteoporosis. Every single bone I have is tremendously weak without acknowledging that there's some variability in different areas of the body. That piece of information for folks can be really eye-opening and very empowering. Oh my gosh, are you saying that I only really have this in this particular area of my body and not everywhere else? That's a sense of relief for a lot of folks. A lot of folks will take this diagnosis and view it as almost like a death sentence. everything. I am so weak. I'm so fragile. I need to be very careful. I'm going to break something, any bone I need to be very, very concerned about. Right. And that's not necessarily what's happening. It's usually in kind of one, maybe two areas that are a concern, particularly folks that are initially receiving these DEXA scans. And the cool thing about where I'm at now, working with folks for over four years, this individual, she's had a DEXA scan every two years. She was on a negative slope, negative three in 2017, negative 3.1 in 2019, negative 3.4 in 2022, and her most recent scan a couple months ago was negative 2.8. This is at her lumbar spine. and when you are able to give context to the diagnosis but then also be able to see over time you'll be able to spot trends and then hopefully be able to potentially reverse trends or slow down trends and we're seeing this at Stronger Life and I know many of y'all don't have the luxury of working with folks consistently you know three times a week over the course of several years but man if we can apply some of the interventions I'm going to talk about here in a second over the course of years you can have a significant influence in a lot of these DEXA scan readings and we're definitely seeing that and you can too. But I think that conversation, the prognosis, them understanding the diagnosis, where in particular that may be, that they understand every single bone in my body is not going to combust under pressure. This particular area may be more concerned, but I'm doing okay in these other areas. It's really good for them to hear that and that can be a more empowering message. OSTEOPOROSIS: TREATMENT Now the most important thing I think is that we take the information from this DEXA scan and then we use it in our plans of care. And so if I have someone that has maybe normal osteopenic in terms of the DEXA scan in their bilateral femurs, neck of their femurs, but then they're kind of borderline osteoporosis in their lumbar spine, for example, as a physical therapist, That gives me something that I can focus on, that I can give targeted interventions to give specific forces and stressors to that area in a very progressive manner, keep in mind, to stimulate a change in that bone mineral density or increase the odds that we can see change in their bone mineral density. So we take that information, use it for our plan of care. Some folks, you may be focused, all right, this left hip, let's load up this left hip a little bit more, do some unilateral stuff, staggered stance type things, not neglecting the other side per se, but if there's a big difference, we may want to give preference to one side or the other. If it's a spine, lots of loaded carries, deadlifts, those types of things where we're getting that axial compression, getting those forces through the spine. We can give target interventions. that's gonna encourage those bones to remodel, to get stronger, or potentially slow down, decline. So we take that information and take it into our intervention piece. Now for the intervention piece, you know, this is a 15, 20 minute podcast. We have a whole week on this in our NYA Level 2 course. But what you need to know is there are three things that are really, really important if osteoporosis is on board. One is balance training. This doesn't directly impact bone mineral density, but if we're able to improve people's balance capacity, I would even go as far to say their fall capacity as well. Do they know how to land? Do they have the balance capacity to even prevent the fall? That whole conversation of falls prevention and falls preparedness that we speak to, particularly in our live course, is really helpful for these individuals. Because if we can prevent a fall or even teach people how to fall in a more efficient or safer manner, you can potentially prevent an injurious fall or an osteoporotic-related fracture. So that's the first thing. Second thing is progressive resistance training. Bones really like progressive resistance training, where we're working up to relatively higher percentages of a one rep max, 70, 80, 85%. We're not going to come out the gate hitting that, but it'll take some time. But there's some really promising studies showing that, man, if people are able to regularly train at those higher intensities, they get really strong. They improve in a lot of the functional outcome measures that we care a lot about, but also their bone mineral density as well. Lyftmore trial is a great example of one group that's been able to show that. And then probably one of the more neglected things that we can definitely implement that can be intimidating for a lot of folks, but I found a lot very empowering for patients once they're able to do these things, and that is impact training. Weight-bearing as well. Loading the bones, but really thinking about the rate of loading. Progressive resistance training puts a ton of force, a bunch of load through that skeletal system that gets really good results. But bone can also respond really well to rapid loading. So think like plyometrics, stomping, heel stomps. step-ups, maybe a plyometric push-up, for example, or a quick bearing of weight through the upper extremities, something along those lines, where we're getting those increased ground reaction forces, we're getting those impact that can give the bones a signal to remodel. You take balance training, you take falls preparedness, sprinkle in some progressive resistance training, and then sprinkle in some of that impact training, and you stretch that out over years, And I will put my money that you're going to see some solid results when your patient comes back and says, Oh my gosh, Alan, look at my DEXA scan I just got. Remember the previous year, about a couple of years ago is like right when we started working together. And then man, I just had this DEXA scan and I've reversed my osteoporosis. We've seen that. Not to say it's going to happen every time, but people have the capacity to change and we often don't perceive that with this particular diagnosis. It is not a death sentence. There's a lot we can do. So understand the diagnosis, but then also understand that prognosis and give your patients context. Get that DEXA scan, look at it, analyze it. It's going to give you a lot of helpful information that they may not have comprehended and it can ease their mind of a lot of concern and worry, but it can also give them, something that they know they can do. And we can take that information and give a targeted intervention to a particular area that may be more troublesome than others. But man, if we combine that balance training, falls preparedness, progressive resistance training, and impact training with folks over a long duration of time, we can see some really significant results. All right, y'all. I appreciate y'all taking the time to listen. Let me know if you have any thoughts, questions, or your experiences working with folks. I do want to make sure I'm not saying everyone's going to get better. Everyone's going to improve their bone metal density. That is not the case. But man, if we can try without causing more harm, I think that's a good thing to pursue. And oftentimes, we can see some improvement. SUMMARY Before I go, I do want to mention our MMOA courses. I already mentioned that level 2 where we talk a lot about osteoporosis. Our online level 1 course is starting May 15th. Our level 2 course is starting May 16th. These are both 8 weeks long, about 2 hours a week, so you'll get 16 CEUs for PT, OT. and we equip you all to be the go-to clinician to best serve older adults in your community. It's likely gonna make you a very, very busy clinician serving these folks. And then our live course, we're gonna be in Bismarck, North Dakota, in Richmond, Virginia on May 18th and 19th. I'm gonna be in Scottsdale, Arizona, the beginning of June 1st and 2nd, and then we'll be in Spring, Texas, June 8th and 9th. We'd love to see y'all on the road or see y'all online. Y'all have a lovely rest of your Wednesday and go check out those Texas games. See y'all!

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