Letters JAOA • Vol 100 • No 5 • May 2000 • 273
Osteoporosis issue needs
addition of extension
exercise findings
To the Editor:
Thanks to the JAOA for the concise Jan-uary
2000 supplement on osteoporosis. One
small addition that would be especially rel-evant
to osteopathic practice is specific inclu-sion
of upper back extension exercises in the
management of osteoporosis.
Loss of height, the most clinically avail-able
indicator of osteoporotic vertebral wedg-ing
and compression fractures, is preceded by
loss of compliance in connective tissues of the
spine and rib cage. In women with osteo-porosis,
thoracic kyphosis is associated with
loss of rib cage mobility, and decreases in
vital capacity, inspiratory capacity, and total
lung capacity.1, 2
Itoi and Sinaki3 studied the effect of back
extensor strengthening exercises on posture
in a group of 60 healthy, nonsmoking, estro-gen-
deficient women with an average age of
59 years. None of these women was receiv-ing
calcium, vitamin D, or estrogen supple-mentation,
and none had had recent back
pain or injury. The group of women was
divided into a control group and an exer-cise
group that practiced a weighted, prone
back extensor exercise 10 times a day for 5
days a week. After 2 years, the measured
thoracic kyphosis in spinal x-rays was com-pared
with the kyphosis in the x-rays taken
at the onset of the study. Among the subjects
with substantial thoracic kyphosis at the
onset of the study, those with significant
increase in back extensor strength had a
significant decrease in thoracic kyphosis of
-2.8° + 4.2°, P + 0.041.
Ten years before, Sinaki and Mikkelson4
studied 59 women with postmenopausal
osteoporosis and back pain over a 2-year
period. They divided the women into 4
groups, with 25 subjects receiving instruc-tion
in back extension exercises (E), 19 receiv-ing
extension and flexion exercises (E + F), 9
receiving flexion exercises (F) only, and 6
controls who received no instruction (N).
They evaluated spinal x-rays for compres-sion
fractures and increased wedging before
and after the study. The incidence of addi-tional
fractures was 89% in the F group,
67% in the N group, 53% in the E + F group,
and 16% in the E group. They did not con-trol
for calcium, vitamin D, or estrogen intake.
The authors concluded that pure flexion exer-cises
resulted in more compression fractures
and that extension or isometric exercises were
more appropriate for women with signifi-cant
postmenopausal osteoporosis.
In the context of a coherent approach to
the management of osteoporosis, we can
expect that timely introduction of upper back
extension exercises will improve kyphosis
and respiratory efficiency as well as reduce
incidence of compression fractures. Again,
thanks for a wonderful issue.
John H. Juhl, DO
Ostrow Institute for Pain Management
New York, New York
References
1. Culham EG, Jimenez HA, King CE. Thoracic kypho-sis,
rib mobility, and lung volumes in normal women
and women with osteoporosis. Spine 1994;19:1250-
1255.
2. Hemholz HF et al. Rehabilitation for respiratory
dysfunction. In: Koltke FJ, Lehmann JF, eds. Krusan
Handbook of Physical Medicine and Rehabilitation.
Philadelphia, Pa: WB Saunders; 1990:858-873.
3. Itoi E, Sinaki M. Effect of back strengthening exer-cise
on posture in healthy women 49 to 65 years of
age. Mayo Clin Proc 1994;69:1054-1059.
4. Sinaki M, Mikkelson BA. Postmenopausal spinal
osteoporosis: flexion versus extension exercises.
Arch Phys Med Rehabil 1984;65:593-596.
Response
To the Editor:
Dr Juhl calls specific attention to the role
of exercise in the prevention and manage-ment
of osteoporosis, and, in particular,
heightens our awareness of the need to more
clearly define targeted exercise interventions
that may be best utilized to manage osteo-porosis.
The type and degree of exercise needed
to prevent osteoporosis is still uncertain;
however, weight-bearing exercises have been
shown to have a positive effect on bone
mineral density in many human studies. 1
Even childhood exercise may have a marked
influence on adult bone mineral density and
may therefore prevent the development of
osteoporosis in later years. 2 Marathon run-ners
achieve a higher bone mineral density
than those who do not participate in this
sport. Tennis players have a greater bone
mineral density in the arm that holds the
racket as compared with the other arm.
Our understanding of the effect of weight-lessness
on bone density has enhanced our
knowledge of the relationship between exer-cise
and osteoporosis prevention. 1 Thus,
weight-bearing exercises are clearly prefer-able
to non–weight-bearing exercises such
as swimming.
For those with established osteoporo-sis,
the prevention of falls is critical. Al-though
many interventions may be used to
prevent falls, exercise programs have been
demonstrated to reduce the rate of hip frac-tures
and vertebral fractures in those with
osteoporosis. 3 The studies cited in Dr Juhl’s
letter represent additional information
important for a better understanding of the
relationship of specific exercise programs
and osteoporosis management. Both stud-ies
shed important information on the role
of back extension exercises in the prevention
of thoracic kyphosis and the avoidance of
compression factors in those with estab-lished
osteoporosis. These data have led to
a commonly held strategy that forward flex-ion
exercises should be avoided in individ-uals
with established osteoporosis. 4
While there is significant data to sup-port
the invaluable role that exercise can
play in the prevention and management of
osteoporosis, Dr Juhl’s letter reminds us of
the need for more research to aid in the
elucidation of the most beneficial type and
Letters
duration of exercise appropriate for the pre-vention
and management of osteoporosis.
Thomas A. Cavalieri, DO
Chair, Department of Medicine
UMDNJ School of Osteopathic Medicine
Stratford, New York
References
1. Drinkwater BL, Grinston SK, Raab-Cullen DM,
Snow-Harter CM. American College of Sports
Medicine position stand. Osteoporosis and exer-cise.
Med Sci Sports Exerc 1995:27:i-vii.
2. Welton DC, Kemper HCG, Post GB, et al. Weight-bearing
activity during youth is more important fac-tor
for peak bone mass than calcium intake. J Bone
Miner Res 1994:9:1089-1095.
3. Physicians’ Guide to Prevention and Treatment
of Osteoporosis. Washington, DC: National Osteo-porosis
Foundation; 1999.
4. Adelizzi R. Shapses S. Recommended Practice
Guidelines for the Diagnosis and Treatment of
Osteoporosis. The Osteoporosis Coalition of New
Jersey and the New Jersey Department of Health
and Senior Services, Washington Crossings, Pa:
Scientific Frontiers, Inc; 1998.
Avoid threat of
malpractice suits
To the Editor:
Here are tried and proven techniques to
avoid the threat of a malpractice suit.
DOs
■ Project a sincere, caring, and pleasant atti-tude.
Try to establish eye contact, and give
undivided attention to all of your patients.
■ At the end of the interview and exam, ask
if there are any further questions.
■ Relate to patients as people and not just
“osteopathic lesions.”
■ Encourage patients to ask questions, and
be willing to explain the answers to them.
■ Respect your patient’s time. If you are late,
be prepared to offer a reasonable expla-nation.
■ Be courteous to your patient’s relatives,
and be willing to answer questions about
the patient’s condition without compro-mising
confidentiality.
■ Return telephone calls promptly.
■ Insist on telephone courtesy by your entire
staff.
■ Resolve complaints and misunderstand-ings
about care, billing procedures, etc,
before resentment builds.
■ Make it easy for patients to obtain fol-low-
up care, or make suggestions as to
where they may receive further care.
DON’Ts
■ Don’t comply with inconsistent medical
practices among your colleagues.
■ Don’t display disrespectful, inconsiderate,
or overbearing attitudes toward patients.
■ Don’t allow patients to view office work-ers
in operation.
■ Don’t allow sloppy or confusing patient
billing methods.
■ Don’t allow offices to appear unclean or
not well-maintained.
■ Don’t ignore the dissatisfaction of the
patient’s family members.
■ Don’t reprimand staff members in front of
patients.
Martin J. Porcelli, DO
Pomona, California
In praise of Dr Wales’
letter
To the Editor:
I am writing to applaud the letter by Anne L.
Wales, DO, “Physician recalls unforget-table
evening in her early career” (JAOA
2000;100:84).
It is incredible that Dr Wales could
devise such an intensive and effective treat-ment
for a patient with pneumonia in the
pre–computed tomography, preantibiotic,
pre–arterial blood gas, and pre–nebulizer
treatment era! Wales’ treatment was based on
her understanding of anatomy; the physio-logic
features of the circulatory, lung, and
autonomic nervous systems; and the patho-logic
features of pneumonia. The good doc-tor
must be very intelligent and well taught,
and, by my count, she must have been in
practice 73 years!
I have given a copy of her letter to the
allopathic and osteopathic medical students
to whom I teach pediatrics, and to my son
who is a medical student, for inspiration.
Verna Jean Turkish, DO
Fellow American Academy of Pediatrics
Westland, Michigan
Manikin
For days I was strapped in my case
For weeks I was cramped in the dark
For months I was hinged at my hips
Then yes, I heard the latch
And soon I was out in the light.
They flopped me on the floor
They pulled my legs out straight
They screwed my arms in place
I love my warm up suit
I hope they keep it clean.
He shook me at my shoulder
He pulled my head on back
He opened my mouth to feel my breath
And called for help, “Are you all right?”
I’ve heard it a thousand times.
She felt the sides of my neck
She marked the spot on my sternum
She pumped and pumped on my heart
“And one and two and three and four
and five”
Then twice he blew out my chest
“And one and two and three and four
and five.”
I’m back in my vinyl den
I watch but it’s all too black
I hear with my feet to my ears
I hope to come out again
And one and two and three and four
and five
I hope out there, you’re still alive.
—John R. Scranton, DO
Water Mill, New York
274 • JAOA • Vol 100 • No 5• May 2000 Letters
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