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Episode 91: LIFTMOR, Not Less: An Interview with Professor Belinda Beck
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In this episode of the Movement Logic Podcast, Sarah and Laurel are thrilled to interview esteemed exercise scientist Professor Belinda Beck, investigator in the groundbreaking LIFTMOR trial. They discuss the necessity of high-intensity resistance and impact training for improving bone density, comparing it to less effective exercises like Pilates, yoga, and walking. Professor Beck shares insights on her LIFTMOR, LIFTMOR-M, and MEDEX-OP studies, underlining the importance of mechanical loading for bone health. They explore the misleading promotion of devices like OsteoStrong or courses like Buff Bones that do not provide the necessary rate of loading or magnitude of load to impact bone density. The conversation elucidates the mechanisms of bone adaptation and defends high-intensity training as essential for combating osteoporosis.
00:20 Bone Density Course Progress
06:28 Guest Introduction
08:25 Interview with Professor Belinda Beck
16:59 Understanding Bone Health and Research
23:46 Bone Adaptation and Remodeling
36:15 Bone Remodeling and Exercise Breaks
37:52 Exercise Types and Bone Response
39:35 Strength Training and Client Engagement
42:37 Effective Exercise for Osteoporosis
44:00 Impact of Weight-Bearing Activities
48:47 High-Intensity Training for Older Adults
53:14 Impact Training and Bone Health
01:02:12 Marketing vs. Science in Osteoporosis Treatment
01:04:09 Comparing Exercise Programs for Bone Health
References:
Get on the wait list for our Bone Density Course
Episode 53: Your Bones Are Bored
Exercise to prevent falls in older adults: an updated systematic review and meta-analysis
Osteostrong: 3 Things You Should Know
Twelve-Minute Daily Yoga Regimen Reverses Osteoporotic Bone Loss
Recommended
Transcript
Misuse of Wolf's Law in Bone Mechanophysiology
00:00:00
Speaker
It's like saying because someone's trained in plumbing, they can do the electrics in your house. It's just totally different. It's misusing Wolf's Law to their own purposes. And if they really did know something about bone mechanophysiology, they would know that isometric loading of bone is static loading. And that is actually...
00:00:21
Speaker
detrimental to bone right back when the very first study was done comparing static versus dynamic loading static we're talking long-term static that's bad for bone obviously holding a yoga pose is is not going to be detrimental but it sure as eggs is not going to be beneficial I'm Laurel Bebersdorf, strength and conditioning coach.
00:00:44
Speaker
And I'm Dr. Sarah Court, physical therapist. With over 30 years of combined experience in fitness, movement, and physical therapy, we believe in strong opinions loosely held. Which means we're not here to hype outdated movement concepts.
00:00:57
Speaker
or to gatekeep or fearmonger strength training for women. For too long, women have been sidelined in strength training. Oh, you mean handed pink dumbbells and told to sculpt? Whatever that means, we're here to change that with tools, evidence, and ideas that center women's needs and voices.
00:01:13
Speaker
Let's dive in.
Introduction to the Movement Logic Podcast
00:01:29
Speaker
Welcome to the Movement Logic Podcast. My name is Sarah Court. I'm a physical therapist, and I am here today with my co-host, Laurel Beaversdorf, who is a strength coach and yoga teacher.
00:01:40
Speaker
Is that right? It is. I'm confused. I'm still teaching yoga and I'm still coaching strength. Not that much has changed. All right.
Progress in Bone Density Course
00:01:50
Speaker
So we just started month four of our bone density course. So we're just past halfway through. And It's fun because we're at this turning point is what it feels like to me and what I'm seeing with how everyone's participating. And Laurel, you can tell me if you feel the same, but the very first month, two months is extremely handholding because everything's new.
00:02:09
Speaker
The exercises are new. The equipment's new. Trying to figure out like how many reps, all of that kind of stuff is really new for people. And it's not beyond them, but anytime you're learning something new, it takes some repetition.
00:02:20
Speaker
And then they have gotten into the to the flow of it. And now we're starting to really investigate what does it mean to add more weight and how are you able to do that successfully? And it's really fun because I accidentally got a screenshot the other day of everybody, the whole Zoom session with all the little windows of people.
00:02:40
Speaker
And I don't know what we were about to do, but every single person is holding either a dumbbell or a plate and they're staring into the camera. Yeah. And it's this amazing shot. and I was like, oh my God, because it was like these ladies, they are ready.
00:02:50
Speaker
Whatever we're about to do, they are ready to do it. And yeah it's just, it's so fun. I love that. I love that. Yeah. It's so much fun to see them starting to step into what I like to think of taking responsibility for their strength. So yeah in the beginning, they are trying to, they're starting to, they're they're figuring out all the moving parts, like you said, tracking their workouts,
00:03:16
Speaker
and getting a feel for the rhythm of the workouts. And then it's right around this time from month three to month four, where they just know what they're doing all of a sudden.
00:03:28
Speaker
And you don't have to say as much in terms of like setting them up for each exercise and telling them which exercise is next. They already know they're already ready to go. It becomes more about fine tuning and reinforcing.
00:03:42
Speaker
So it's really cool to
Empowerment Through Strength Training
00:03:44
Speaker
see. Totally. One of the things that in the earlier months, we really had to do a lot of work on form wise. There's still a few people that that need a little adjust like assistance or adjustment, but the overhead press with a barbell or strict press, as it's also known with a barbell, very few women.
00:04:02
Speaker
I was thinking about this the other day. Very few women are encouraged to press weight overhead. You might go into your sort of high intensity class and you're doing like rows Or maybe you're doing some sort of lat pulldown kind of a thing.
00:04:16
Speaker
But it is rare for them to be like, all right, hold this dumbbell and now you're going to press it directly overhead. And so then when you have to do it, not just with an individual dumbbell in each hand, but one bar. So then that changes where your hands are facing because you're holding one bar and you're going to push that single bar up overhead.
00:04:32
Speaker
I have to say, when I first started trying to do the overhead press, I flailed really hard. And there's even, I put it in my Instagram feed because it's like, oh, wow, she just really doesn't know what the hell she's doing.
00:04:43
Speaker
And it didn't, it felt weird. It didn't hurt, but it was like, it felt awkward. I felt awkward. And then what I really discovered was I just wasn't strong enough. And as soon as I started doing more of it and I got stronger, now it's one of my favorite things to do.
Importance of Proper Form in Strength Training
00:04:59
Speaker
And I think part of why it's one of my favorite things to do is there's something very like, triumphant Hulk about holding a bar over your head with your arms straight and it's like resting on your shoulder blades. Like you're right in the right position. You're just, that's what I feel like when I do them.
00:05:15
Speaker
I love that. I love that. Yeah. It's amazing what changes when you have more strength. Yeah. And it's amazing how much easier it is to focus on the minutia of form when you have a little bit more strength. And what that has taught me over the years is that when you're working with someone who's new to strength training, you can just save your breath on all the little minute cues and changes and this and that and the other thing and let the exercise look how it looks.
00:05:49
Speaker
Don't go... to levels of like danger or extreme inefficiency. If there's something that can be corrected, obviously, correct it. But don't worry if it doesn't look perfect because the form will become better and look better once that person has more strength.
00:06:10
Speaker
So just give them a couple of months and don't overwhelm
Beginners' Fears in Strength Training
00:06:15
Speaker
them. I think Something that I think unfortunately happens a lot of times is that beginners to strength training get overwhelmed with all the things they're hearing about how they're doing it wrong and they're going to get hurt. right And so they get discouraged or they start underloading.
00:06:33
Speaker
They start doing a lot of low load mobility exercises because their form isn't just perfect in the squat or their form isn't just perfect overhead. And okay, instead take this dowel or this PVC pipe and work on your form first.
00:06:46
Speaker
When unfortunately, none of the things that are quote unquote wrong in the exercise are going to change until this person is just stronger. yeah Let them build that strength. That's like one of the most freeing things. I think I've learned both on the practitioner side of doing the exercise as well as on the coaching side of coaching. It is, is it's okay if it doesn't look perfect.
00:07:06
Speaker
Yeah, absolutely. And I find that with like when I'm teaching somebody how to deadlift at the clinic and I'll give them the dowel to begin with to learn the form. But as I'm doing it, I'm very often saying it's going to be easier as soon as I give you the 15 pound barbell and I can see them giving me the eye, but then they're like, oh my God, you're right. Cause like that 15 pounds for most people is very doable, even though it sounds intense to a lot of them, but they've definitely found that, oh yeah, though a lot of the time the weight itself actually forces better form to happen.
00:07:36
Speaker
Because you there's not you don't have the option to put it all kinds of different places. The weights, oh no, this is where I go. Yep. The body is wonderful at self-organizing around a task or to accomplish a task.
00:07:48
Speaker
So yeah the task is lift the weight and suddenly your body can workshop that and figure it out in the moment. Nice. yeah All right.
Introduction of Professor Belinda Beck
00:07:58
Speaker
So I'm very excited about today's episode. Yes. I don't want to like...
00:08:03
Speaker
I don't want to compare all of our wonderful guests that we've ever had, but this one is a big deal. Yeah, she is a big deal. I happened to mention in my class today yesterday, my bone density class yesterday, that we were interviewing this person.
00:08:17
Speaker
And a few people recognized the name immediately. And then when I gave the context of who she is, all of them were like, oh my God, that's amazing. So I've already pre-excited a bunch of people to let the cat out of the bag.
00:08:32
Speaker
I don't think a cat is in a bag, but anyway, we're today we are very fortunate to have Professor Belinda Beck as our guest on the show. She is now if you also are like, I don't know who that is.
00:08:46
Speaker
You might be familiar with her very well known in our in the nerd world research that was called the Liftmore trial. which is where she took a group of postmenopausal women with osteoporosis, had them doing heavy strength training and impact training, and not only saw almost no injuries, which is not the sort of like received wisdom, which is people with osteoporosis shouldn't do anything hard because they might hurt themselves. And she's like, have to do something heavy.
00:09:15
Speaker
to make the osteoporosis better so we should at least try and they had an incredible success it led to more trials she has a bone clinic where you can go and work with her if you happen to live in australia and she's just really smart she was interviewed on peter atia's drive podcast a couple of months ago and i don't know i just sometimes i'm like let me just find a person's email and see what they say if i'm like hey do you want to come on our podcast And she was very gracious and she has agreed to. So we're so excited to to talk to her.
00:09:46
Speaker
And we hope you enjoy this episode as much as we enjoy talking to her. are
00:09:55
Speaker
We are delighted to have Professor Belinda Beck as our guest on the show today. She is a professor of exercise science in the School of Health Science and Social Work at Griffith University in Queensland, Australia.
00:10:08
Speaker
Now, you may not recognize her name, but if you've listened to our podcast at all, you will recognize her work as she was one of the researchers in the LIFTMORE trial, which we talk about a lot.
00:10:19
Speaker
In the LIFTMORE trial, post-menopausal women with osteoporosis and osteopenia effectively improved their bone mineral density by doing heavy strength training and impact training. In 2015, Professor Beck established the Bone Clinic,
00:10:32
Speaker
where you can take part in her Onero program, which is the strength and impact training program that came out of the Liftmore trial. A little later on in the show, we're going to talk about all the research Professor Beck has done on building bone in the older population, namely Liftmore, Liftmore M, and Med-X-OP.
00:10:51
Speaker
But in the interest of time, we don't need to go into a lot of detail about these studies yet, but just to orient listeners, Professor Beck, sorry, Belinda, can you briefly explain how these trials were designed and what the most salient findings from them were?
00:11:10
Speaker
Sure.
Findings of the LIFTMORE Trials
00:11:11
Speaker
the All of the trials were proper randomized control trials. So we recruited people with low to very low bone mass and we randomly allocated them to either a high-intensity resistance and impact training program, which we now call O-Nero, or to control.
00:11:31
Speaker
Now, in the case of the Lift More study, control was what used to be ah your typical exercise recommendation for for osteoporosis that you might get from your doctor or not very well-informed exercise practitioner,
00:11:47
Speaker
which was just a bit of walking, a bit of stretching, some lunges, calf raises, just anything to fill 30 minutes that we knew wouldn't grow bone. And and they had when they needed to have exposure that was the same as the high-rip program. So twice a week, 30 minutes for eight months were bull both programs.
00:12:06
Speaker
Same thing for for the Lift More M trial, same clinical trial structure, same recruiting of men over the age of 50 because we didn't have that menopause landmark. So were looking for people who were beginning to show age.
00:12:23
Speaker
And instead of the exact same structure in Liftmore, we we were lucky enough to be given a biodensity machine, which I believe is the precursor of Osteostrom.
00:12:36
Speaker
So we were able to run a parallel trial of this biodensity slash Osteostrom-like machine with our high-rip program, and then we had a self-selected control, which was just to continue their usual activity.
00:12:53
Speaker
Now, there's a reason for that, and I can tell you about that later if you want. won't go into too much detail. Obviously, a fully randomised trial is better. Then the MedXOP trial was the third trial where we were interested to know whether bone medications would interact with O-Nero and for the purposes of improving the outcomes of both.
00:13:17
Speaker
So because none of us are physicians, we weren't able prescribe meds. So what we did is we recruited people on and off meds. They had to have been on 12 months of established meds.
00:13:30
Speaker
And then we randomized them to either the O-Nero program, the high-rep program, or In this case, we decided to choose another established program that was marketed for bone, which is called Buff Bones, which is a Pilates program, a modified Pilates program.
00:13:49
Speaker
And that was our parallel trial. So instead of using a control group, because my my sense was that this was not going to improve bone mass because Pilates typically does not. It's too low intensity.
00:14:01
Speaker
So that was the design for that. But of course, we had to stratify our randomization based on meds. So we had half of each group were on or off meds. And then we obviously for each trial, we compared between groups, the outcomes after eight months.
00:14:16
Speaker
All right. And so what were just in summary, what were some of the outcomes, the salient findings from each of the studies? So basically LiftMall was this, it was really the step change program. Nobody had done this before because we were all very nervous about hurting people with this kind of heavy lifting.
00:14:36
Speaker
And so you can imagine how delighted we were when we showed that we actually did have this lovely increase in BMD at the spine. We didn't see a massive increase in BMD at the femoral neck that we were expecting with heavy loads through the hip.
00:14:53
Speaker
Instead, we were able to analyse those data with 3D HIP software and the very cool thing ah we found was that even though BMD didn't change, it didn't go down, but it was maintained, instead the HIP seems to modify its shape and structure in such a way to increase strength. So it thickens the cortex of the femoral neck and the cool thing in the Liftmore trial is that happened at the lateral arm.
00:15:21
Speaker
cortex of the femoral neck, which is exactly where the fractures begin to propagate. So this this is really cool. In Lyphomorph for men, we found the same thing. the biodensity slash osteostrong machine did not work to improve bone mass.
00:15:38
Speaker
And there are a couple of the functional outcomes that it was that even improved five times sit to stand. But other than that, it really didn't work. whereas the LIFMOR program, i so the HIRIP program did, and it also showed geometric changes with the three d hip analysis.
00:15:54
Speaker
But interestingly, the changes are more on the medial side of the cortex. I'm not really sure why that is, why it's different for men. The other interesting thing about the LIFMOR for Men study where we did study the biodensity machine is that there were five incident fractures in that biodensity group.
00:16:15
Speaker
Now, we didn't identify them actually in training when the people were there. Nobody said, oh my back just really hurts. But on a comparison between baseline and follow-up of our groups where we did lateral scanning of the spine, so we were able to measure the front, the middle, and the back of each vertebrae.
00:16:35
Speaker
we could very clearly see that in that bio-density group there had been five fractures. And of course, no fractures in the HIRIK group. You know, that's a concern to me. That's not a no-harm intervention. invention no Now, in the MedXOP study, same thing, saw an improvement in the HIRIK group and...
00:16:55
Speaker
we saw actually a loss of bone in the buff bones group. So it was interesting that if you think of these as four groups, so if we'd have buff bones on and off meds.
00:17:06
Speaker
If they were off meds, they lost bone. If they were on meds, they gained bone. If they did high RIT, not on meds, they gained the same amount of bone as if they were on meds.
00:17:18
Speaker
If they were on meds and on high RIT, Again, at the spine, they gained roughly the same amount of
High-Intensity Resistance and Impact Training
00:17:25
Speaker
bones. So it didn't really make much difference at the spine. At the hip, though, it did seem to improve bone density a little bit more if they were on meds as well. Yeah.
00:17:35
Speaker
Just for listeners hearing high RIT, high RIT refers to, correct me if I'm wrong, high intensity resistance and impact training. That's correct. Yep.
00:17:45
Speaker
Great. Thank you for explaining those three studies. And it's essentially the same thing as O'Neuro, except in the Lift More studies, we just did the high-rit exercises.
00:17:57
Speaker
But at the bone clinic, we've added in some balance and mobility, and we call it O'Neuro. And MedXOP used the O'Neuro design, yeah.
Bone Density Measurements Explained
00:18:06
Speaker
Thank you. And we're going to talk more about each of those a little bit later on because there's lots of... the i was Sorry.
00:18:12
Speaker
and just I was like grinning while you were talking. Within four minutes, you're telling us that Pilates is not enough for bone density. And I just feel so vindicated because Laurel and I scream that constantly. And we get a lot of, but what about the springs? Nope, not enough.
00:18:29
Speaker
Okay. So let's establish... a baseline understanding for our listeners who are primarily maybe yoga teachers, Pilates instructors, movement teachers, some personal trainers, some PTs.
00:18:41
Speaker
But let's talk about the main aspects of bone that that determine a bone's strength or its resistance to fracture, which would be bone size, bone density, and bone architecture.
00:18:54
Speaker
Can you give our listeners just a brief, like plain English rundown of what these each refer to and why they matter? Sure. Bone mineral density, which is measured from when your doctor refers you for a a bone density test, that's what is being measured because this is an X-ray machine. So it's a very broad brush strokes kind of measure. You're lying on a machine and the X-ray goes through your body. It's detected at the top.
00:19:18
Speaker
And what it's detecting is the density of the material it's going through. And because it's an X-ray, it picks up minerals. So that's what it's picking up. It's picking up the mineral in your bone. Now, the theory is the more mineral in your bone, the more bone you have.
00:19:33
Speaker
The more mineral it detects, the more bone you have. Now, that is largely true because bigger bones, bigger bone density.
Understanding Wolf's Law
00:19:42
Speaker
There are ah some minutiae with there we we probably don't have time to go into, but bone mineral density is picking up the mineral in the bone tissue. It does not parse out anything about bone shape.
00:19:53
Speaker
It doesn't look at cortical bone or trabecular bone. It's just a very broad measure. And the wonderful thing is it's very low-dose radiation. It's very easy. It's very cheap. And it has this printout that doctors can understand and explain to their patients.
00:20:09
Speaker
And it's a way of monitoring your response to drugs. It's not a great, as you've just heard from my description, it's not a great way of measuring change in response to exercise because that change does seem to be very targeted to the loads that are put on And bone is really sensitive to loading and it tends to adapt right where the loading is.
00:20:33
Speaker
So if you have a and DEXA scan of your hip, for example, and you've had a bit of modification of bone into, you've moved bone to an area of the hip where it best withstands a force, but you've actually removed a bit of bone from somewhere else because in the process,
00:20:52
Speaker
it will look like you haven't changed. It looked like the exercise hasn't been effective. As we've shown, and others have shown with other actual measures, pre-dimensional measures like a CT, that that is that does occur.
00:21:05
Speaker
And then when you when you model that with bioengineers, very clever with how they can model the actual shape of bone and put theoretical loads on it and can see how that affects the strength of bone. You can see that bone is just so incredibly clever.
00:21:22
Speaker
it knows where to put the bone, the extra tissue to strengthen it. Based on Wolf's law, bone does adapt ah to the loads that are put on it to best withstand future loads of the same nature.
00:21:35
Speaker
And that's exactly what we're talking about here. Fantastic. I think you just answered my next question, which was about how the DEXA scan measures just bone density and how that allows us to understand the overall strength and health of bones, which is that It's just taking into account the amount of mineral in a bone.
00:21:53
Speaker
And the more mineral, likely the more bone, but it can't measure size and it can't measure architecture. And it's the best we have, right? You mentioned the QT scan. Is that what it's called? Did I say that right?
00:22:05
Speaker
The CT scan is just like regular CT scan that you would have at medical facility. you've got a big round donut gantry and you can, as if researchers have enough money, they can write those into their to their projects, and they can use that very specifically measure actual bone changes and shape.
00:22:25
Speaker
The problem with that is it's pretty high-dose radiation. why It's certainly not something that you would want to expose kids to or pregnant women or anybody who has had a lot of radiation in the previous
Alternative Methods for Measuring Bone
00:22:37
Speaker
years. So we use instead PQCT, which is a peripheral,
00:22:42
Speaker
quantitative computer tomography it's a small donor very low of this radiation but the problem with that is you can only measure the tibia and the forearm so you can't actually measure the sites that are clinically significant such as the hip or the spine there it's also not really great resolution so there is a high resolution qct pqct and that does yeah mean that's a fab if i can afford it i have one of those in my lab but again It's just a small machine that can only really measure the ends of the bone. You can't get your whole body into it.
00:23:18
Speaker
Yeah, and it and it seems CT scans and the other two scans you mentioned, too, would come at a pretty high cost relative to the DEXA and for that reason are maybe prohibitive.
00:23:30
Speaker
Yes, certainly for research studies, it's much more difficult. do we We can run a pretty cheap study and and none of our studies have been funded apart from the PhD student ah funding.
00:23:41
Speaker
and We could not have afforded to have either CT or MR. Yeah. And I would imagine as well for like across the country, medical doctors, it's at this point that the DEXA scan is ubiquitous. It's really everywhere and it's the standard. It may not do everything that we need, but it's the best tool we have. And it's probably as well useful measuring yourself against yourself over time to get a sense of has this activity improved my bone density or not.
00:24:07
Speaker
That's right. And the other thing is too, it it takes considerable amount of time to analyse a scan from a CT. You have to have the the right software. And then if you hand it over to the doctor, they would have to understand how to interpret it. Yeah, just these are research tools. They're not well accepted.
00:24:24
Speaker
And I probably should also mention that there has also been ultrasound around for measuring bone for many years, but mostly that's available in the heel scanners. So you just put your heel in the ultrasound device and the sound wave passes through calcaneus or your heel bone.
00:24:40
Speaker
And that gives you some measures that are quite correlated to your risk of fracture. But the precision is not that great. And again, it's only measuring the heel bone.
00:24:51
Speaker
Now, in recent years, you've probably heard of REMS, which is the Echolite is a new ultrasound machine, which is designed to measure from the spine and hip. This is pretty early days.
00:25:03
Speaker
And yeah, the jury's out a little as to exactly how this is performing. Good to know. I wanted to talk about, i listened to your interview that you did on the drive with Peter Atiyah,
00:25:16
Speaker
And one of the things you mentioned in that interview that I thought might be good to bring up is that bones actually bend as part of the process that helps build bone density. But I think for the general population, the idea of your bones bending sounds like something you'd want to avoid.
00:25:34
Speaker
Can you break down for us why the bending happens and how that actually helps to strengthen your bones? Yeah. Again, Obviously, I'm a complete and utter bone geek, and I just love everything about this tissue. It's so amazing, and every time I think about how it adapts, it just it bowls me over again.
00:25:53
Speaker
it's the system is set up so beautifully to respond to mechanical loading. The design of the tissue works. is that it has, people think of bone as being inert. When you think of a chicken bone, you just think, oh, here's this lump of bone.
00:26:07
Speaker
In that really hard cortex that makes up the shaft of bone, it's full of holes, and those holes are full of little bone cells, and they're all connected by channels. They all hold hands. it's like this great big society inside the bone.
00:26:24
Speaker
So they all speak to each other, but they're bathed in fluid, and the fluid, is the key to the signaling because you can imagine if that bone was a sponge and instead of being hard it's easier to think of it as you squeeze a sponge that is full of water you squeeze it to one side and the water gets squeezed out of the squashed side and into the more open side that's exactly what happens with bone but of course on a very tiny scale so when i talk about bending we're not talking about a piece of spaghetti we're talking about a very tough substance
00:26:59
Speaker
that bends a tiny amount, it's it's actually micro strain. So strain is a unit of bending and You can pick it up with a strain gauge. It's very sensitive, but obviously you can't see it with a naked eye.
00:27:12
Speaker
But that bending squeezes the fluid through, and it's that movement of fluid that those bone cells that are bathed in the fluid picks up and goes, oh, wait, that's bending a
Role of Calcium in Bone Health
00:27:22
Speaker
lot. i can There's a lot of fluid going past my cell membrane.
00:27:26
Speaker
I'm going to send a signal saying, if you keep bending like that, we're going to break, so we've got to do something and then start laying down bone to try and prevent that bending more than would cause a fracture. Now, they never modify the bone or adapt to such an extent that the bone doesn't bend at all. And if you looked at a tibia, the shin bone, from the side, you'll see that this is not like a pipe. It doesn't go straight up and down. In fact, it has a subtle curve.
00:27:59
Speaker
anteriorly so that it's concave posteriorly towards the back and that encourages bending with every load so that bending is absolutely central to the adaptive ability of bone all the other bones are the same yeah it just makes me think about how when i was in pt school and you start studying anatomy or if you ever There's ah a gentleman named Paul Grilly who did a lot of pictures and videos of a whole series of femur bones side by side. And you see the variety and the rotation of the shaft and all of that, of that position of the head and the neck and all of that. And the idea that's not just random, but that it's there on purpose to promote the bone's ability to get stronger is I love that so much. That's such a cool concept.
00:28:46
Speaker
And it also made me, I live in in Los Angeles. So it's to also made me think about how, buildings here when there's an earthquake, they sway. And you would think I don't being in a building that's swaying sounds like a very bad idea generally, but that's so that the building doesn't break during the earthquake. So it feels similar in the sense that like it allows some movement so that it doesn't actually fracture.
00:29:07
Speaker
Absolutely. Everything about the skeletal system is um designed to, to protect the body basically and physically protect organs, but also protect it from breaking, allow it to move, give the muscle something to pull on, but also protect from a lack of calcium. Now, calcium is used in so many different physiological systems, muscle contraction, relaxation, nerve conduction and all of those things. If we don't have calcium available in our system for those processes, we're in trouble.
00:29:44
Speaker
So most of us don't constantly have a glass of milk on hand that we can put in our stomach so it's available for all of those processes. What do we do? We go to the calcium bank.
00:29:55
Speaker
What's the calcium bank? That's our bones. So this process of remodeling is constant. It's not all about ah response to mechanical load.
Heavy Lifting vs. Impact Training
00:30:05
Speaker
It's a chemical response as well. When TH is in your system, it's signaling that when you need ah to upregulate and downregulate that remodeling process.
00:30:17
Speaker
And the one thing your buildings in LA and everywhere over the world and bridges don't have, and this is where bone absolutely wipes the floor with them, is the fact that it's self-healing.
00:30:29
Speaker
So you get little cracks in bone and the bone cells, what that normally does is it goes through those little handholds of those cells that are in their networks and that signals the bone there's a crack there, osteoclasts come in and resolve that area and replace it with completely new bone, not a scar, new bone.
00:30:50
Speaker
Yeah. So cool. I wanted to talk a little bit about how you are using in your research both the heavy resistance strength training component and then also the impact training component.
00:31:06
Speaker
Is there a difference between how heavy lifting and impact training improve bone health? do they Are they just different roads to the same and or do they actually affect the bones in different ways?
00:31:20
Speaker
Yeah, it's a... million-dollar question, i think you would say they affect the bone in kind of in different ways, but at the very high level.
00:31:34
Speaker
At the low level, it's affecting it in the same way. I mean, the mechanical, the adaptive response is the same, but the pathway is slightly different. So we think.
00:31:45
Speaker
Now, whether or not one is superior to the other ah resistance training or impact training is ah question for the ages. We've never really been able to figure it out.
00:31:57
Speaker
We've just looked at meta-analyses of intervention trials and tried to weigh out which was most effective. And the take-home message and the reason why O'Neara is high-red, why it's both,
00:32:08
Speaker
is because I think both are necessary. You probably will get a response from each, but it's better if they're combined. So ah don't know if you can hear those kookaburras in the background, but I'm feeling so Australian right now.
00:32:26
Speaker
I can't hear them. I wish I could. It was just like on cue. Cue the kookaburras. What are kookaburras? A kookaburra is a bird. it's the They call them the laughing kookaburra because their bird call sounds like a laugh.
00:32:42
Speaker
But it's also slightly spooky. So if you see a scary movie, quite often they use kookaburra noises. oh Like in the Amazon, even though there's no kookaburras there. yeah it's It's like the red-tailed hawk.
00:32:54
Speaker
yeah That they always use where there are no maybe red-tailed hawks. or That's right. They'll show a bird that's not a red-tailed hawk, but they'll put the red-tailed hawk call. Sound over it.
00:33:05
Speaker
yeah I grew up in England, so I grew up with a song called Oh God, what is it? Kookaburra sits in the old gum tree. And then I don't remember the rest of it, but that's how I knew what you were talking about. it' hey That's how that's right.
00:33:17
Speaker
Yeah. yeah No, they're great. They're big and raucous and they eat snakes. so they so Oh, wow. Yeah. Yeah, we want to keep them around. Yeah. i think you I think you actually answered my follow-up question, which is whether a heavy lifting on its own would be useful. Yeah, and I can talk more about probably the the thing that distinguishes heavy lifting or any kind of lifting and impact is the speed of loading. And I think that's what's key because...
00:33:44
Speaker
If you look at the animal research, we know that high strain loads from Reuben and Lanyon's turkey work back in 1985, 1984, they showed really clearly there's a dose response. The heavier the load, the more the bone responds.
00:33:59
Speaker
But then later it became evident that you could actually apply lower loads if you applied them fast. So the rate of loading is important too. So I think...
00:34:11
Speaker
If I, in my head, I'm thinking about that osteocyte syncytium, that's the network of bone cells bathed in fluid, and I'm thinking high strain means bending the bone quite a lot, so it's really squeezing the fluid quite a lot.
00:34:27
Speaker
Low strain quickly is more bending it fast and shaking it up. So both ways are stimulating the cells to adapt, but it's in a different way. Okay.
00:34:39
Speaker
Very cool. That brings us nicely to our next question here.
Varied Loading Techniques for Bone Adaptation
00:34:43
Speaker
Can you tell us a little bit about cellular accommodation? This idea that bones get bored, so to speak, when the stimulus they're experiencing is too repetitive or goes on for too long of a duration?
00:34:57
Speaker
Yeah. So I can't tell you why that happens. I'm not a molecular biologist and I've never gone down that rabbit hole, but certainly we know that There is no point giving the same stimulus over and over to a bone cell because, again, Ruben and Lanyon showed that 36 cycles of a single mechanical load was exactly almost exactly the same as 360 or 1,800 of the same stimulus. It just stops reacting because it goes, okay, enough, I've heard you.
00:35:29
Speaker
So translating that to the human condition, and I just told this to my students in class yesterday, you would get more response out of bone from sprint training than marathon training.
00:35:41
Speaker
Yeah. This is something I've been wondering about. So if you would entertain me for a moment and let me ask this very kind of long question, but it does need a little bit of background. We know that, as you just said, slow to moderate pace running is not very osteogenic due to how repetitive the impact is given its long duration and its cyclical nature.
00:36:03
Speaker
My question is, can we assume that lifting weights, even though it's not a cyclical activity or nearly as repetitive as running, could become repetitive as well due to a similar bone response to the repetitive loading? I guess I'm wondering if there is potentially a good reason to change the exercise or exercise variation every couple of months to load that same group of muscles, but with a slightly different applied load.
00:36:30
Speaker
Or if there is value in withdrawing the exercise stimulus for a period of time and then reapplying it. And the reason that particular question comes to mind is this is something that was looked at in a study done on rats. The title of the study is mechanosensitivity of the rat skeleton decreases after a long period of loading. Sarah and I talked about it on a podcast episode titled Your Bones Are Bored. Mechanosensitivity of the rat skeleton decreases after a long period of loading but is improved with time off.
00:37:00
Speaker
So it appeared that in this study, the rate of bone remodeling sped up after loads were taken away but then reintroduced after a break of several weeks. So the rate of bone remodeling was increased after reintroducing the stimulus after a break. So all of this is just really asking if cellular accommodation applies when we're talking about strength training.
00:37:29
Speaker
Is there value in changing the exercise or exercise variation so that the bones don't get bored? Is there value in really stopping training in a specific way to train in maybe another specific way or just stopping training for a while and then restarting it?
00:37:43
Speaker
so that we increase the rate of bone remodeling or the bone keeps listening, the bone keeps responding. no is the short answer, i think, because from my understanding, I'm not aware of the study you mentioned of stopping for a couple of weeks and restarting, but I am aware of the work done back in the nineties, I believe of testing the same number of loads applied across a day but broken up into bouts of loading.
Optimizing Exercise Routines for Bone Health
00:38:20
Speaker
So it's the same principle as what we were talking about before. If you did 3,600 bouts in one go, you're going to get less response than if you did that, divided that by six and did six bouts of 60 throughout the day.
00:38:37
Speaker
Did I get my maths right? Probably not. So it doesn't have to be weeks break. It just has to be a break. We don't know exactly how long and what's the difference between rats, mice and people, but having a break between the loading bout and so that you're breaking it up.
00:38:55
Speaker
That's the important thing. I don't think there's ever there's any evidence to suggest that taking a break is going to be good because what will happen is your bones will go, oh, So you're not loading me anymore? Okay, I don't need this anymore. And the osteocorosis will upregulate and they will start their resorption. And that's going to happen pretty fast.
00:39:14
Speaker
So it's not its bone is a use it or lose it and you need to use it every day. Now the other question about do you need to change the type of exercise that you're applying to get more response out of the same bone, I'm assuming you're asking, and that's Also, it seems like a good idea.
00:39:39
Speaker
it it makes sense intuitively. But when you drill down to the physics ah of what bones actually experience during different loads, you'll discover that actually they experience very similar patterns of loading. Because of what I was telling you before about the actual shape, bone drives the nature of its own loading because of its shape. It's always going to bend. You might do ah a leg extension on a machine and then you might do lunges and thinking you're doing two different things.
00:40:12
Speaker
But because the tibia is that shape, it's bending the same. The loads are exactly the same. There might be different massitudes. But they're the same. And so yeah joint reaction forces and and ground reaction forces can can be applied in different ways. But ultimately what the bone sees is going to be very similar. I'm not saying it's exactly the same.
00:40:34
Speaker
Certainly playing tennis is going to apply some different load to running. because you've got side-to-side action, of course the loads are going to be subtly different but largely broad scale the same.
00:40:48
Speaker
So it is ah it seems like an intuitive and sensible approach to change your – but as long as you're loading as many bones as possible, as high as possible,
Effective Exercises for Osteoporosis
00:40:58
Speaker
as often as possible with breaks in between, you've really just nailed the recipe. The recipe is not complicated.
00:41:05
Speaker
Yeah. That's great to know. From a strength standpoint and from the standpoint of maintaining your client's interest in the program, I'm speaking from perspective of personal trainer, bringing variety in can be helpful, right?
00:41:23
Speaker
it It can be helpful to change the exercise every training block or every six weeks, eight weeks, three months. To bring in that variety, to keep people engaged, but also to work on strength and slightly different specific ways depending on what the goal is, the performance goal or maybe the hypertrophy goal or whatever it is.
00:41:44
Speaker
But it's good to know actually that with bones, as long as i'm going to say loads are high enough and there is sufficient breaks, which we would have to have if the loads are high, right? There's no way around it. Once you've reached high intensity, suddenly the rest times increase as well, that the bones ultimately are going to respond the same as long as the similar mass of muscles is being trained, right?
00:42:13
Speaker
Yeah. I tend to, so let me give you for example, it took a long time for us to discover the recipe for the optimum program.
00:42:23
Speaker
And I'm not just talking about the optimum exercises. I'm talking about the optimum way to deliver something that is feasible, affordable, and appealing to this demographic.
00:42:38
Speaker
And so twice a week, we do it for 45 minutes at the clinic. It can be done shorter, but if you have fewer people in class, but 45 minutes is roughly what you need. So it's brief twice a week intervention.
00:42:53
Speaker
If you've got that recipe and it ain't broke, we we think why fix it. The fabulous thing is that actually people don't get bored because the challenge is the weight.
00:43:08
Speaker
And the for them, the challenge it's an internal challenge. It's not a competition. You know that 90-year-old Martha is never going to be able to lift what? 60 year old jennifer's lifting they don't look sideways they admire each other but they it's a competition with themselves we've had people come into the clinic for nine and a half years and they are not bored one of the ways we change it up is we do change the balance and mobility exercises that are in there so that keeps that's necessary to train balance but no it's they know they're coming for their bones
00:43:42
Speaker
And so they're dedicated to this. They actually like the fact that it's a technical program and they're learning it and they have to concentrate. And so when they look at it as some of them may look at it as a little repetitive, but they got five other days a week to do the other stuff and you can change what you want in that time.
00:44:04
Speaker
Cool. Thank you for answering my questions. I wanted to talk a little bit now about what methods of exercise can really meaningfully impact osteoporosis. And obviously I i can't speak to what the medical community and the media promote in Australia, but in the U S we get a lot of mixed and frankly, confusing messages around what type of exercise actually helps with bone building.
00:44:29
Speaker
We see a lot of articles in popular media. There was just recently one in the New York times. And for many doctors that doing quote unquote, weight bearing exercises like walking can help with osteoporosis.
00:44:42
Speaker
And this has always felt very like cover your ass to us in the sense of they're promoting the kind of exercise that doesn't need supervision, but it's not really also going to move the needle on someone's bone density.
00:44:54
Speaker
And then at the same time, we know that something like swimming, that is not a bone building activity, even though the swimmer is generating incredible forces on their bones by their muscles working because they're in this almost weightless situation by being in water. Weight bearing by itself is not enough, but force without weight bearing is also not enough.
00:45:16
Speaker
So can you help us understand why we need load applied during a weight-bearing activity to impact bone? And how do we help people like understand this in a way that doesn't leave them more confused than they probably already are?
Role of Gravitational Forces in Bone Health
00:45:30
Speaker
Yeah, to a certain extent, the answer to that question is one of the eternal mysteries of bone. The mystery appeared when astronauts started going into space in 1969, they just measured all of this calcium being excreted and thinking, where is this coming from? Well, could only be coming from one place.
00:45:49
Speaker
You take away gravitational loading and that force through the body and your bones just somehow know to get rid of mass. It's like a we are evolutionarily programmed to minimize our weight for the forces that are put on us because it's the most efficient way to exist, to have least mass to move around.
00:46:12
Speaker
And that's one of the amazing intangibles of the body, I think. It's interesting that the astronauts don't lose very much bone from their upper extremity and their head.
00:46:24
Speaker
Those are the extremities that are not really exposed to the gravitational forces so much, or at least the weight-bearing gravitational forces when they're Earth-bound. It is coming away from the bones that have had that weight-bearing impact removed.
Limitations of Walking for Osteoporosis
00:46:41
Speaker
Nobody really knows why it's so important, but it probably does have something to do with the rate of load application that I was talking about before, the speed of the movement of the fluid through bone when it's being bent.
00:46:56
Speaker
The direction of the loading perhaps has something to do with it because of the direction of the channels in bone. And we shouldn't say that swimming is, I never want anyone to take away the notion that swimming is no good.
00:47:11
Speaker
Swimming is better than nothing. You've got to get off the couch and do something. So the muscle loads that you're putting on your bones, even in the pool, are better than nothing. But they are not going to prevent the loss as well as a weight-bearing, higher strain activity.
00:47:27
Speaker
So, yeah, anything's better than nothing. With the caveat that I do worry about the recommendation to walk, again, i am a very pro-walking person.
00:47:42
Speaker
It's so cheap, easy, manageable by most people. So when I say that walking is useless for bone, which it is, and it it that's within the context of the fact that anything is better than doing nothing.
Need for Progression in Exercise Programs
00:47:57
Speaker
and But the problem is if and the doctor says, Mrs. Smith, ah you have osteoporosis, here's your prescription for XYZ, and yes, you should do some exercise, go for a walk every day, that person has not assessed whether Mrs. Smith is actually safe to walk.
00:48:19
Speaker
And if you see Kathy Sherrington's falls, Systematic Review, think it might have been back in 2017, showed that walking is actually associated with an increased risk of fractures because that Mrs Smith might be way too frail to go walking on her own.
00:48:38
Speaker
So it's not a no-harm prescription. It's not for everybody. Walking might be good for Mrs Smith, but she needs to be clamped to the side of her carer or somebody else who's going to prevent her from falling.
00:48:52
Speaker
Yeah. One of the things we talk about as well, you mentioned how Pilates or other low, low intensity exercises don't move the needle similar to walking.
00:49:03
Speaker
And when we get arguments from people that like, yes, they do to an extent, it's yes. For someone perhaps who's very deconditioned, like the initial load or impact of those exercises will make some difference. But what we are constantly arguing back is that there's no progression.
00:49:20
Speaker
So whatever impact that might have had, it's going to run out pretty quickly. A hundred percent. Yeah. Okay. I just wanted to make that point. The principle of initial values applies. The lower you are, the more you're going to respond because the the more your bones will be able to detect the signal.
00:49:39
Speaker
If you ask somebody, who is very deconditioned, even to pick up, just do a dumbbell squat, they're probably going to react to that. But if you ask an Olympic powerlifter to do that, their bones aren't going to change. They're already fully adapted to that level of, that's probably not even going to bend their bones at all.
00:50:00
Speaker
Yeah. Sarah and I always make the point we lift heavy weights. And if we were suddenly to stop and do yoga, all the people who say yoga builds bones, like we would actually probably lose bone, right? Because we'd be engaging in low intensity, whereas before we were engaging in high intensity exercise.
00:50:21
Speaker
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00:50:37
Speaker
You might be wondering, how do I know if I'm lifting heavy enough to actually improve my bone density? How can I keep getting stronger without getting injured? What's the best way to modify lifts if I have joint pain or past injuries?
00:50:50
Speaker
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00:51:03
Speaker
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Changing Norms in Women's Strength Training
00:51:26
Speaker
um All right. The LIFTMORE trial has really shifted the narrative around heavy strength training for older women, an activity this population has repeatedly been left out of and absent from.
00:51:37
Speaker
Given that still prevalent societal norm, did you experience any pushback from participants in the study about lifting heavy barbells or doing drop jumps? Did they take to it with complete enthusiasm or was there some trepidation or fear?
00:51:57
Speaker
So I would say there probably was some trepidation, but the problem is it's a little bit of a biased sample because when we recruit, we would say to them, are you willing to do, this is what the study involves, would you be willing to be randomised to a group that in which you will be doing this?
00:52:17
Speaker
So they had already agreed to do it. So well I suppose that somehow biased the sample in a more like ah a more natural real world situation where people come into the bone clinic all the time and they walk in for their their baseline assessment and they'll walk past the gym and look over and go, oh, that'll never be me.
00:52:39
Speaker
and And then they have their consult and they have their beginner class and they're taught how to do it and then they get promoted into a neuro class and suddenly that's them. So they, yes, absolutely. There are people who, when you have, I'm looking at your bar in the background and I can't tell from it, but it looks like one of our trainer plates. So just the 2.5 kilo ones that you put on the end, they look huge and heavy and scary.
00:53:03
Speaker
Then they realize actually it's not that hard. It's not that heavy. and And as soon as they have that aha moment, it's, oh man, I can do this. Yeah. Yeah. And I look cool doing it too. And then they're in the kitchen the neck within six months and taking the lids off the jars for their husbands.
00:53:20
Speaker
Totally. exactly Yeah. And then their husbands, oh no, my wife is about to become stronger than me. Maybe I should start lifting weights. ah So you mentioned in the research papers of establishing the the persons, the individuals, one repetition max.
Risks of Testing One Repetition Max in Osteoporosis
00:53:38
Speaker
Yeah.
00:53:38
Speaker
I believe. And so I'm wondering, can you tell us a little bit about how, what that looks like? ah First of all, did you test each person's one RM at certain points in their training? Do you test their one RM for listeners?
00:53:52
Speaker
A one RM, a one repetition max is the heaviest load a person can lift one time and one time only before needing to rest. So can you tell us if you did test their one RM, what that looked like and yeah, paint us a picture.
00:54:05
Speaker
Yeah, sure. In Lift More and Lift More M, we did do 1RM testing. It was with great trepidation because these people were at high risk of fracture.
00:54:16
Speaker
We did it because we needed to. We really needed these studies to be ironclad and to show that people this is actually the intensity we were working at. so we could hand on heart publish our findings saying this is where we were.
00:54:31
Speaker
Now, MedXOP, we didn't do 1RM testing because I personally think it's too risky and there's no need to expose people to that level of risk.
00:54:42
Speaker
If somebody has a T-score of minus four at the spine, there is no way in the world that I would say they should do a 1RM test. It's just too heavy. And they get so competitive with themselves, they just really want to do it and so they jerk and they crank the worst possible thing you can do if you're fine so we certainly don't do it at the clinic definitely not but there are other ways i'm sure you would know strength and conditioning coach you can definitely test for percentage of one rm thing that the your listeners might not know what an amrap is but you would you can test in that manner and that's how we normally do it for our current those projects but otherwise my coaches are so well trained they can
00:55:25
Speaker
You can just tell when somebody's not lifting heavy enough. If they put a bar down and you can see they're not even breathing and they turn around and they can lift again within 10 seconds, that is not even close to being heavy enough. Yeah, yeah, definitely using tempo to gauge how heavy something is for someone and then doing a repetition max test is, yeah, a lot more conservative, I would say, approach to figuring out what someone's 1RM would be on a chart or on a calculator.
00:55:53
Speaker
question for you about the impact training. I remember reading in Lift More M that the impact participants experienced in the drop jumps, six times body weight force or that it was measured to be at times six times body weight when they were dropping and landing.
00:56:11
Speaker
And so my imagination, I'm trying to figure out what height were they dropping from? Was it a standard height? I think they were jumping up to a bar, right? And then dropping from there. So was the distance they were dropping from dependent on their height relative to the height of the bar?
00:56:28
Speaker
Or do you have a range of heights that they were dropping from? um We're just wondering six times body weight. What would that look like in terms of distance dropping?
00:56:39
Speaker
Yeah, totally depends. And Laurel, if I tell you this, I'm to have to kill you.
00:56:47
Speaker
Then don't tell her because I need her around. It's a secret. Is it a proprietary secret or is it that you're worried that people are now going to go start jumping off of things? It's both.
00:56:57
Speaker
yeah The Onera program is licensed, so there is intellectual property around it. So we do, and we have published the program. And so the exercises are out there, but how you deliver it the subtleties, the nuances, that's the real key to the to the the effectiveness and the safety.
00:57:15
Speaker
So that's why we licensed the program so that people would actually be trained on how to deliver it safely. And the answer to your question is actually quite complex. And again, it's dependent on the coach. It's totally dependent on the the individual.
00:57:29
Speaker
So their height, their capacity, they how much knee away they have. Mostly you ask these people, when was the last time you jumped? And they probably say, when I was about 10, about 60 years ago.
00:57:40
Speaker
so you have to really introduce this gradually. And I imagine that the forces their bones are experienced are also going to depend on their footwear. Yeah, that's fine. Surface that they're jumping onto. um So another question is, what is the threshold in terms of body weight or G-force that someone would have to experience before you would start to make changes
Impact Thresholds for Effective Bone Training
00:58:08
Speaker
to bones? I've heard it's four times body weight.
00:58:11
Speaker
Is that true? Do you have, is there a threshold that is out there that people try to reach when they're trying to make a change to bone with impact training? i can't imagine that anybody would have that metric in their head as a guideline in a practical situation.
00:58:32
Speaker
i it's not a, it's not something that you would tell to somebody in the gym that you're aiming for. It's, I believe there have been some some numbers in print, probably out of Catherine Brooke Wavell's group who did the hip-hop study. They were doing hopping and they measured, i believe, the ground reaction forces in reaction to that and looked at individual response.
00:58:56
Speaker
So I think you're probably in the ballpark area, but the the real answer is nobody knows. And I strongly suspect it's completely different depending on the individual response.
00:59:07
Speaker
depending on their bone state and what they've been exposed to before. So, you know, it absolutely is one of the exercises where you have to take extreme care and really individualize it because, as I mentioned before, sudden loads, they may be osteogenic, but they can also be really dangerous.
00:59:27
Speaker
And you just have to use the example of imagine ah a stick of a certain width. If you bend it slowly, it's going to bend and bend and bend and finally break. But if you bend that stick fast, it's going to snap pretty fast.
00:59:41
Speaker
So the rapid loading of bone is not necessarily wise for someone with weak bones. So you do have to absolutely titrate this loading for the individual.
00:59:53
Speaker
Yeah, definitely. Yeah, I know from running, I'm a runner, that it forces the force increase is hyperbolic with an increase of speed, right? So it's very low at slow speeds. And then the faster and faster you go, it doesn't increase linearly, right? It increases even more so than you would expect with a straight line. Yeah.
01:00:11
Speaker
That makes a lot of sense. Yeah, I think a lot of people just want to know what the activity they're doing that does involve jumping, right? Is it high enough jumping, right? So if you dance and you jump a little bit, tap dance, if you jump a little bit, if you run, right, or if we know that's too repetitive, but if you do other types of jumpy, bouncy activity that isn't so cyclical and isn't so repetitive,
01:00:33
Speaker
Is it enough? I think that is the question in a lot of people's minds. And as you said, there's so many variables that are going to in impact, no pun intended, how much force is going through your bones, including how heavy the person is, shoe wear, surface area, and then also their preparation to experience those forces. And so it's maybe a question we're never going to have an answer to.
01:00:53
Speaker
We just know that impact, at least cohort studies on athletes show athletes that do high impact activity in their sport tend to have stronger bones than ones that don't.
01:01:05
Speaker
And I guess we'll just have to live the question of how much is enough. yeah i if I would hate for any patients to be listening and and saying, okay, this means I've got to do a whole bunch of jumping because each person needs to have a proper assessment and be guided on that. Because you know how many times does a vertebral fracture happen if somebody is walking down the stairs and they misjudge, they think they're done, but suddenly there's another step and they jolt down and they have a fracture.
01:01:36
Speaker
That's impact loading and that's what we would recommend for many people, jumping off a step. But for some people it is absolutely contraindicated. So it is an individual thing and, again, it's the reason why we don't talk too much about the program out of school, if you like, because we do need to assess the individual and and titrate that loading.
01:01:57
Speaker
Yeah, and and you're working with people who have been diagnosed with osteoporosis, whereas people who teach movement of some sort are not necessarily, right? They're working with the general population who's interested in preventing osteoporosis.
01:02:10
Speaker
And so that's why these the answer to these questions would be of great value in order to know that we are doing enough before it becomes a problem. But I understand that there are certain questions that we might not be able to know because we don't have the lab equipment.
01:02:26
Speaker
Yeah. or we don't have yeah the amount of information that we would need to actually be able to answer that question because it's complex. And also the fact that in that, if you're talking public health, community center, everybody just turns up and does a class together.
01:02:41
Speaker
In that class, you can guarantee there's probably, if it's an older group, there's probably 20% that have osteopenia or osteoporosis. So you don't know by looking at somebody unless they've got established kyphosis.
01:02:54
Speaker
So you do even have to be Careful at that level. Prevention, I 100% hear you, it way better than ah dealing with fracture. But you probably do need to assume, even if someone's not diagnosed, that there is osteoporosis in that community group.
01:03:12
Speaker
So... With the LIFTMORE-M trial, like we mentioned at the beginning of the interview, the difference between that and the LIFTMORE trial, apart from the fact that it was with men, is that you also compared them doing another group of men doing exercises on the biodensity advice device, which is called OsteoStrong in the US.
Critique of OsteoStrong and Balance-Focused Interventions
01:03:34
Speaker
And the paper concluded that machine-based loading using the biodensity device provided a largely insufficient stimulus for musculoskeletal or functional benefits.
01:03:47
Speaker
And we get a lot of questions from people about osteo-strong. I know several people who were told to do it by their doctor. And people ask us if it's effective and it's safe. And we tell them there's not a lot of evidence out there about it because the evidence that we've been able to look at is actually really, and the evidence that they promote on their website is actually very poor quality.
01:04:09
Speaker
And not specifically to their device. They just say, this should work because of this mechanical loading data, which is completely unrelated to their device. And so it was very validating for us to read that you also thought that it was poor quality technology.
01:04:28
Speaker
Since there is such a lack of strong evidence for this intervention, and it's actually expensive, like you go do this 15 minute session and it's, i don't know, it's easily maybe 50 to $100 or something for 20 minutes.
01:04:41
Speaker
Why do we still have so many doctors referring their patients to OsteoStrong? Do we have an answer Also, you noted that it was actually potentially dangerous. Yeah. Yeah.
01:04:51
Speaker
Look, it it's marketing versus science, right? My facility is a research facility. It is a health facility. It is a business. But I don't advertise. These guys have obviously a massive marketing budget. They've probably got a whopping great venture capital loan and they've just set this thing up in a way they've gone. And that's business.
01:05:12
Speaker
And so they're able to, they've used a really cool name that that makes people think that it's going to work. And I call mine O'Neuro because it's the Latin for overload. and so But so this is the difference between science and business. And we see it everywhere that Business wins in when it comes to profile.
01:05:32
Speaker
So doctors hear osteo, they probably think that osteo-strong is O'Neuro. It starts with the same letter, right? Doctors do not know anything about exercise. They don't have time to read into the minutiae. And so it's not their fault, but it's a shame. I'm doing my very best to try and get the word out. In Australia, I'm doing an implementation trial here to try and insert O'Neuro into the osteoporosis model of care. We've been running the stop practice study for the last year or so.
01:05:59
Speaker
But in in the States, there's a lot of work to be done, and thankfully people are starting to pick up licenses, and the word is getting out. Thanks to Atiyah's podcast that really gave us a shot in the arm, and Margie Bissinger as well is getting the word out, and you guys will be too. I can probably send you the link to Laura Gian Gregorio's video that she made describing the research but or the evidence behind OsteoStrong.
01:06:23
Speaker
And it'd be really great for people to go there, click on the link and listen to what she says, because she gives a very objective description of what evidence there is. Is this from the University of Waterloo?
01:06:35
Speaker
That's right. Yeah. Yeah. we've We've shared that far and wide. I think it's a really great people with only a lay understanding she can understand it. so So yeah. yes Yes.
01:06:49
Speaker
So then we wanted to talk also about the MedXOP trial, which stands for medication and exercise for osteoporosis and how you compared the high RIT to buff bones, which is a low intensity Pilates based training.
01:07:05
Speaker
And it showed that high RIT was more effective in increasing spine bone density, posture, and boosting muscle strength compared to buff bones. That both helped with functional performance, but that high RIT had greater benefits for leg and back strength. And that medication appeared to enhance the effect of exercise at certain bone sites.
01:07:25
Speaker
I'm very curious personally, I think Laurel is as well, but I am especially curious. Was there a reason that you selected BuffBones specifically as the comparison program? Yeah, because when you run a clinical trial and you're testing an intervention, the argument can always be made that the control group, if they're not sufficiently like the contact that the intervention group is having, there can be bias that just because the people in the intervention group are seeing and interacting with the researchers on this regular basis, as it could somehow change their behaviour. So what we wanted was an exercise group that could come and see the investigator for supervised training the exact same amount as in the intervention group. So it was essentially an active control because, like I say, I was reasonably certain
01:08:19
Speaker
that Pilates was not going to be sufficient to increase bone mass. So I thought we were quite safe using it as a VSATS control, but we didn't know. So ultimately, it was more a parallel designed intervention trial rather than ah controlled trial. The fact that the people in the Buff Bones group were exposed to Melanie, who was the researcher, the same amount as the High RIC group allowed us to show that any difference between groups was not related to this inequity of exposure and any bias that might come from that. Having conversations after class, should I be eating this amount of calcium and salt, those sorts of things.
01:09:00
Speaker
It also allowed her to really get to know cohort very well so she could talk about other things that were going on in their lives. You could track falls and fractures and things like that, that you always do in intervention groups. So it was a really nice way to really, i get two bangs for our buck that we were able to test buff bones because it hadn't been tested before. There's no science behind it and also have a control group that that really was very similar in exposure to the high record.
01:09:30
Speaker
There's a lot of companies, a lot of individuals that we see who have tried to emphasize that their program that is a low intensity program, like a Pilates or something working with like small hand weights is beneficial to bones. And then when they get called out in some way or realize that actually their program is not necessarily going to do much for bone density, they tend to shift focus.
01:09:56
Speaker
and change their message to, oh, don't worry about your bone density. What you really need to worry about is whether or not you're going to fall. So we're going to work on your balance, which our program does help with, and then you won't fall.
01:10:09
Speaker
And this seems to me like a very unhelpful and honestly, potentially unethical redirect because people who are at a risk for falls can still fall. Even if you do balance training, I work with senior patients all the time.
01:10:22
Speaker
Have you seen this as well? Absolutely. But this is where people like me for years arguing with doctors that exercise was good for bone. And this is a wing and a prayer. We didn't have evidence that exercise was doing anything more than just maintaining bone.
01:10:38
Speaker
until we did the Lift More study, my mantra was, even if it's not growing bone, it's stopping them falling. That is our mantra because it is true. It is extremely important that we stop people from falling.
01:10:51
Speaker
But number one, arguing that your program is good just because it prevents falls is just half the goal. The goal is both prevent falls and increase bone.
01:11:03
Speaker
Why would you deny that to your patients? When everybody has limited resources, both time and money, when they're going to do ah workout for their bones, they want to get both.
01:11:16
Speaker
and And luckily, and Nero is doing both. It's improving functional outcomes that are risk factors for falls. It's improving leg extensor strength and back extensor strength, improving posture.
01:11:28
Speaker
all of those things that are going to increase your risk of falling. Why not do both? So I don't want to sledge other people's programs and I certainly don't want to suggest that doing them is not beneficial because, as I keep saying, anything is better than doing nothing.
01:11:45
Speaker
yeah But I do think if people are resting on their laurels and thinking that this is going to be enough, it's not.
Misconceptions of Yoga in Bone Health
01:11:53
Speaker
One of the things that that I've seen as a claim in yoga specifically, and I don't know if you're familiar with the Lauren Fishman research paper about 12 yoga poses that can reverse osteoporosis, but it's...
01:12:07
Speaker
We talk about it a lot because the yoga world got very excited about it because they were like, oh, another thing that yoga is good for. But the paper itself is full of, it's very faulty and it doesn't actually prove what it claims it proves.
01:12:19
Speaker
But one of the arguments that people, what's that? Shocker? Yeah. ah But so one of the claims that they are making is also a Wolf's law based claim. They're saying that because when you get into a yoga pose and you hold the pose for an extended period of time, you're getting this isometric contraction that's pulling on the bone. And that is initiating the Wolf's law response of laying down more bone.
01:12:46
Speaker
and that could potentially create changes in bone mass, though we can't measure bone mass or bone architecture. Do you think that this is a plausible argument?
01:12:58
Speaker
I'm going to say, you based on your face, that's a no. It's like saying because someone's trained in plumbing, they can do the electrics in your house. It's just, it's totally different. It's misusing Wolf's law to their own purposes. And if they really did know something about bone,
01:13:16
Speaker
mechanophysiology, they would know that isometric loading of bone is static loading and that is actually detrimental to bone. Right back when the very first study was done comparing static versus dynamic loading, static, we're talking long-term static, that's bad for bone. Obviously holding a yoga pose is is not going to be detrimental, but it sure as eggs is not going to be beneficial.
01:13:44
Speaker
thank you And words putting somebody in deep forward flexion with a minus four T score is going to be detrimental. yeah It's well known that yoga has been associated with vertebral fractures when they're doing those deep forward flexion poses.
01:14:00
Speaker
i don't have anything against yoga. And it's wonderful for all manner of things and people should do it. But if you've got osteoporosis, stay away from those poses and don't let anybody tell you that it's going to be growing bone because it's just not.
01:14:14
Speaker
You heard it here first, folks, or you heard it here first from a professor. You've heard it from us for a while.
01:14:22
Speaker
Thank you so much, Belinda, for joining us. It was a total honor. I learned so much in this episode and I just want to thank you for giving us your time and your knowledge and your expertise. It was wonderful talking to you. My absolute pleasure. i obviously love talking about bone. So any opportunity. Thank you so much for coming to talk to us on the podcast. Like Laurel said, we really appreciate it.
01:14:46
Speaker
What are the best ways that people can get involved with O'Neuro or with the work you're doing at the bone clinic? What options are there for people? So the first thing, if they don't live near us at the clinic, that they should do is Google Onero locations. And what that will pull up is the Onero map. And it's a map of the world.
01:15:07
Speaker
And you navigate, you just click and drag around that map to where you live and zoom in. And you'll see a whole lot of little red tags. And you click on the red tag and the drop down will show you the contact information for the Onero provider.
01:15:20
Speaker
Now, There are not nearly enough on your providers to manage the demand around the world. So if there isn't one near you, if you do what I just said, and it's just blank, there's no red tags, go talk to your local physical therapist or exercise physiologist and see if they're interested in a license, in which case,
01:15:40
Speaker
They just need to contact me. In that case, probably Google O'Neuro Academy because that's the training site for O'Neuro. That has a click here and you'll be able to send an email to Belinda and we'll get them sorted.
01:15:54
Speaker
Great. Wonderful. Thank you so much. We really appreciate it. And yeah, ah it's, I also, I just got excited about the fluid and the bones and the bending and all that stuff. It just really got me jazzed about bones again. So, so really, we really appreciate you taking the time. and And we're also just grateful that you've done this work because it's really life-changing. I do a lot of heavy lifting strength training with my older patients, the older women in particular. And I, it's so satisfying. Yeah.
01:16:22
Speaker
for them to discover that they're stronger than they think they are and that they can get even stronger. and They come originally to increase their bone mass, but at least at the clinic, and then they stay for all their friends. So it's a social, there's a lot of social isolation, as you would know, in the older age group.
01:16:41
Speaker
This creates a little tribe for them and they where they fit. They've all got something in common. Yeah, it's lovely. Yeah, that's wonderful. All right. Thank you so much. I won't take any more of your time.
01:16:53
Speaker
are
01:16:59
Speaker
Okay, well, that was, I mean, i'm I've got almost no words for how fantastic an experience it was talking to Professor Beck. It was just, it was so gratifying, I found, and I'm sure you found as well, Laurel, to talk to her and to hear that we, you know, interpreting the research correctly, that was maybe one of the most satisfying conversations I've ever had.
01:17:22
Speaker
Yes, agreed. I enjoyed it immensely, not only from the standpoint of like a student, I learned things, but also from the standpoint of feeling kind of validated in a lot of what I've concluded through my in investigations, however lay person they have been conducted.
01:17:44
Speaker
I loved it. It was very gratifying to get to talk to a personal celebrity. yeah to me yeah to hear some expert insider information around this landmark study and so studies rather and to just feel pumped about what we're doing what we you and I Sarah are doing with movement logic and to know that we are we're on the right track you know Yeah, absolutely. I definitely felt a little starstruck myself. I can't lie.
01:18:18
Speaker
One of the other things, and this might just be like me personally, one of the other things I really like enjoyed or respected or appreciated, I guess, is the way that she spoke in that when she was talking about her research, she would say things like, we think,
01:18:32
Speaker
da-da-da I think, but out which is how researchers talk, right? Because they have a very deep understanding of the fact that research is always just giving us suggestions based on best available research, but there's always some problem with research, right? It's never, there is no perfect study.
01:18:51
Speaker
So it's rarely, if ever, we know, it's usually we think. it's rarely this proves, right? It's always research suggests. There's a healthy level of skepticism and humility with how researchers communicate the information that they've gathered from the research they've done. And it's in contrast to the language that we will often use in marketing from influencers, right as well as in the language that we will often hear from people who clearly have a lot to gain from whether or not their research
01:19:25
Speaker
is going to be influential in the decision making of the the general population in terms of, you know, I want my research to show that this is true so that it influences people to behave in a certain way or so that I can potentially gain some type of something from that, right? And then we'll hear, you know, misinterpreting of the data. We'll hear and an unhealthy level of confidence. We'll hear a lack of humility. We'll not get enough qualifications for statements made and claims made. We'll hear a lot of bias. And so that is the opposite
01:19:59
Speaker
of what you would want from a scientist. right well the scientists You want the scientists to always be doubting their findings, yeah to always be leading with skepticism and actually exhibiting a healthy amount of uncertainty, honestly. That's what leaves space for your mind to change in the face of better evidence.
01:20:20
Speaker
That's why our tagline is strong opinions loosely held. Right. And Laurel and I have an upcoming episode in which we dissect an email that we received from Dr. Lauren Fishman.
01:20:33
Speaker
And I think it might be interesting just for people when they listen to that episode to contrast the language used by each of these professionals just to really see the difference.
01:20:44
Speaker
Okay. Thank you all so much for listening. We really hope that you got as much out of this episode as we did. We both want to have her. We were both like, i could talk to her for hours, literally hours.
01:20:56
Speaker
And there's so many more things that I would love to ask her. So perhaps she will be incredibly kind and come back on the show at some point. We would love it. Yeah. Please rate, review, subscribe, all the things that everyone always tells you to do at the end of a podcast, and yet most of us never do because it seems like a hassle.
01:21:15
Speaker
It does make a really big difference in terms of getting the show that we do for free out there to more people. So if you have a moment, hit the five stars or however many stars you think you deserve and subscribe. That also really helps. And then if you really feel like it, you can just write a little a little review.
01:21:33
Speaker
Let's see, every all the studies and everything discussed will be in the show notes. And we'll see you in two weeks.