Ep 217: Beast mode to build bone, with Dr Belinda Beck

[00:00:04] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research to quality practice. I'm Claire Ardern, the Editor-in-Chief of the Journal of Orthopaedic and Sports Physical Therapy. It's great to have you listening today. Low bone mass, a precursor to osteoporosis, affects 50% of women over the age of 50 and 33% of men. To help our older adults combat this issue, proper loading is essential to

[00:00:33] give the body the stimulus it needs to grow, remodel and improve. But what data do we have to show that this approach is safe and effective? Today, we'll be interviewing Dr Belinda Beck. Dr Beck is a professor of exercise science at Griffith University, Gold Coast, Australia. Her work, primarily related to the effects of mechanical loading on bone, has involved both animal and human models from basic to clinical research. Her particular focuses have been exercise interventions across the lifespan for bone health and understanding and managing bone

[00:01:02] stress injuries in athlete and military populations. In 2015, she established the Bone Clinic, a translational research facility and clinical practice in Brisbane, providing the evidence-based O'Neill exercise program for osteoporosis, which has been licensed for delivery around the world. Before we jump into the interview, we have a quick disclaimer for our listeners. Dr. Beck is the author of the Liftmore trial, which informs the programming and structure of the evidence-based O'Neuro program. I am a licensed O'Neuro provider, but during our talk today, we are focusing on

[00:01:30] discussing the Liftmore trial only rather than O'Neuro itself. We hope you enjoy. My name is Dan Chapman, owner of Summit Physical Therapy and Performance in Baltimore, Maryland. And I'm Chelsea Kuman, a physical therapist and athletic trainer at Stanford University Athletics. Dr. Beck, thank you so much for sitting down with us at JOSPT today. Pleasure. Lovely to be here. Oftentimes, we don't find super aggressive research trials when it comes to loading and

[00:01:56] exercise trials, right? The Liftmore trial is the complete opposite of that. And obviously, I'll let you get into the methodology and the demographics of the participants. But before we jump into that, I just wanted to really know what was your thought process behind the design of the Liftmore trial? What made you want to design a study like this? Well, it was the abject failure of exercise interventions for osteoporosis that had been

[00:02:24] run previously. For the previous 10 years, I had been going to conferences and listening to doctors saying, I don't prescribe exercise to my patients. There's no evidence that it actually increases bone mass. And I couldn't argue with them because on average, that is actually true. All of the previous exercise trials hadn't really been able to increase bone mass. Some of the better ones were

[00:02:52] able to maintain, prevent loss, which is a good thing. So that was the argument that I used to say, exercise is really important for bone. It prevents loss. And even more importantly, it prevents falls. And that's what causes 90% of hip fractures. But the doctors would sort of facepalm me and say, yeah, but I can hand them this drug and then measure them in 12 months. And they've probably increased 6% of the spine. And that's a difference I'm looking for.

[00:03:18] So with that kind of history, but also my background in animal research, I knew that mechanical loading will make bone adapt and you can increase bone. So if I compared what had been found in the animal research to what had been tested in the human research, I discovered there was a big

[00:03:41] mismatch. You can't expect to find a change in human bone if you're not loading the bone enough. So what needed to be done was a heavy loading program that we could test whether number one, it worked, but really importantly, number two, if it was safe. So that's what Lift More was all about.

[00:04:05] We really loaded them up. We knew that you needed both resistance training and weight bearing impact to really get a response out of bone. It needed to be high enough magnitude to get that. We knew that you needed to do it for a fair amount of time to be able to detect it on a DEXA. Bone doesn't adapt quickly. So it was an eight month intervention. And we also knew psychologically, we had to address

[00:04:31] what people are willing to do. So doing twice a week for 30 minutes seemed like the smallest amount we could apply as an intervention, given that bone doesn't need a lot of exposure as long as the magnitude is high enough. We thought that would work and lo and behold, it did. Hey, what a wonderful segue. I love the origin story because now we get to go into,

[00:04:56] can you just give us a brief overview of the Lift More trial, like especially the general demographics of the population, of the participants, and then just like the general program that you just kind of hinted at? The other thing that was missing in many of the previous exercise trials was recruiting the actual people who needed the exercise. So again, it was this fear

[00:05:19] of hurting people that made investigators screen out people with osteoporosis. So instead, we were screening in those people. And we really, you know, unless somebody was an absolute hazard to themselves, we would recruit them if they volunteered, irrespective of what their T score was, as long as they were less than minus one. So they had to have at least osteopenia and almost half of the

[00:05:48] sample actually had osteoporosis by T score. So minus 2.5 from a DEXA scan. And they could have prevalent fractures, you know, they could have existing kyphotic, so you know, like a kyphotic deformity. The only things we really screened out were conditions that we weren't certain were safe. So if someone had grade four NEOA, we'd say no to that because we didn't know if we were going to fire

[00:06:16] that up. And, you know, chronic frozen shoulder, no to that. So we wanted generally healthy over 60 because we needed to get clear of menopause. As everyone would probably know, this is this increased temporary sort of five to eight year period where bone mass is reducing rapidly because of the withdrawal of circulating estrogen. Over 60-year-old women, we recruited about 100 of them,

[00:06:44] and we randomly allocated to either this high intensity resistance and impact training twice a week to 30 minutes, or a home program of low intensity exercise. And, you know, ethically, you can't give a control group nothing when you know that they are at risk of fracture. So that's why we did this active control. We didn't want to give them something that would reduce our ability to detect

[00:07:10] the difference between groups. So we just gave them what we knew was going to be a relatively ineffective bone program, but it might improve their function and balance so that they might be less at risk of falling. So it was just a bit of walking, a bit of stretching, some lunges, toe raise, calf raises, bicep curls. And we just gave them a set of one through three kilo weights and they could progress as they felt that they needed to. But that was twice a week, 30 minutes,

[00:07:39] exact same sort of exposure to the exercise. We kept good track of adherence for everybody. And there was pretty good adherence with that home program, over 80%, which is pretty good. And for the hybrid group, there was almost 85% adherence. And then, of course, we did lots and lots of testing at baseline. We tested on DEXA, so we were looking at biomineral density,

[00:08:02] but we also tested on PQCT, which is peripheral quantitative computer tomography. This is like a mini CT. It's got a small gantry that they put their forearm or their leg through, and it takes a slice at the distal end of radius and tibia. And then further up, it takes a cortical slice at about

[00:08:24] 66% site. And with those, we had a way of looking at bone geometry, but also it has out the cortical and trabecular bones, so we could look at those as well. We also looked at ultrasound, broadband ultrasound attenuation of the heel, which is a marker of bone strength. And then we did a hundred different functional tests, timed up and go and sit to stand and all of those things. And then, you know,

[00:08:53] quality of life and all that stuff. So we have postmenopausal women, osteopenia and osteoporosis. We have a control group. And then what does the intervention lifting program look like? Basically, a bunch of compound movements. These are standard sort of Olympic bars and plates, and it's plus an impact activity. And these are loaded at 85% 1RM. So because this is heavy lifting,

[00:09:23] we didn't know if people could tolerate it or if it was safe. So we were so conservative. We had this month-long introductory program of teaching people the actual movements with broomsticks and giving them lead-in progression exercises that didn't even involve lifting a bar. And within a month or so, we realized that we could move much faster. It was way too conservative and we didn't need to do all

[00:09:51] that stuff. Within two weeks, we had people on bars lifting and away they went. And, you know, we were still careful. You cannot be a cowboy when you've got somebody with, you know, a very low bone mask. You have to be very, very careful. Attention to technique, really, really important. It is a, probably a very broad rule that people are far more conservative with old people than they need to

[00:10:17] be. Because remember, those old people are just you in a couple of decades. It's, there's nothing that happens to you and makes you a different person. Yes, you do get, you do lose strength and function if you don't keep using it. But that doesn't mean that you can't get it back. Yeah. I love that take. I love that. Yeah, absolutely. And I mean, and for those people who don't know what 85% is,

[00:10:45] correct me if I'm wrong. But, you know, this program was really looking at, you know, five sets of five. The Lift More trial was looking at five sets of five. Is that accurate for heavy compound movements? And then you wanted people to be maybe having one or two reps in reserve? That's right. That's a heavy lift. So if you have Aunty Marge, who's 90 and hasn't lifted anything heavier than a

[00:11:10] teacup in the last 20 years, then her 85% 1RM, it could be 10 kilos. Whereas, you know, the person who has been a marathon runner their entire life, so they're quite fit and somewhat strong, but their bones are terrible because they, you know, have just didn't eat enough. That person probably there, 85% 1RM, it might be 40 kilos. They might walk straight into a bar and be fine. So it's not the

[00:11:37] absolute amount. It's just, it's the perception of load to the individual. If you remember, what was your lowest T-score in the intervention group? I believe it was sort of in the 3.8 sort of area. We was, it was pretty low and we may have even screened out some who were less than four because, you know, this was the first time this had been done and we, you know, we did need to be a

[00:12:03] little bit careful. But somebody with a T-score of minus 3.8, that person is a, an absolute fracture risk. And so what were the results of the Lyftomor trial? We went on to have people gaining up to 12% at the spine, but on average, it was about a 3% gain for the mean of the high intensity resistance

[00:12:27] impact training group with about a one and a half percent loss in the control group who were just doing that low intensity. So we had this sort of net benefit of over 4%, which was really fabulous at the spine. Now the hip was a different matter and this was complex and confusing and frustrating to us. The most anybody ever gained in BMD at the femoral neck was 6%. And there were some people

[00:12:55] who didn't gain anything. And the average, the mean for the whole group in the high reed group was 0.6%. So it wasn't even 1%. And we couldn't understand this because many of these people were lifting really heavy and it didn't make any sense that this highly loaded proximal femur wasn't getting bigger or wasn't at least getting more dense until we analysed it with our 3D hip software, which actually used the same

[00:13:24] scan and created a 3D model of everybody's femur. And it allowed us to look at the shape and structure of the bone and see change from baseline to follow up. And lo and behold, we had this beautiful change in femoral neck geometry. It got wider and the cortex got thicker. And that is a really powerful way

[00:13:47] to strengthen any structure. That's why, you know, beams are made wide rather than narrow. You can use the same amount of material in a tube, but make it wider and hollow and it will be much stronger as a wide, thin cortex tube. That's the same principle at femoral neck. So we had this almost 30% difference between the control

[00:14:12] group and the hyric group at the lateral cortex of the femoral neck, which is just a, you know, it was a wonderful finding because it showed us that right where the femoral neck fractures occur, this program was thickening and strengthening the hip. How, so you have to have the software to be able to look at that. How close are we to being, be able to like doctors being able to look at that or make it as easy as a DEXA scan? Is that pretty far off in the future or are more people using that?

[00:14:38] So it's not something that people are going to do in everyday radiology clinics. Most of them don't have the software and most of them don't want to, will not want to spend the time. And then of course, at the other end, the results that come out, most doctors are not, would not be familiar with. Maybe it's coming, might be heading in that direction. I'd love it if, if we were, but it's reason,

[00:15:04] it's expensive software. It's $10,000 for the software. So not everyone's going to buy that. The big goal of the study was to find out if this changed BMD, but also we needed to find out if it was safe. What happened then? Excellent question. And it is sort of the elephant in the room. The very cool thing about it is that we had one minor back strain and that person had two weeks of, or two sessions, I think,

[00:15:30] PT came back and kept lifting. We did dexascans from the lateral side so that we could look at each vertebrae and we could measure anterior, middle and posterior of each vertebral body to see whether there'd been any crush fractures and there was nothing, absolutely nothing. The idea that this is going to cause fractures in everybody is just not true. There's no evidence

[00:15:53] from that study. So I think that was, yeah, it was a fantastic outcome, but the key is supervision and teaching of perfect technique. You know, you can't just say, here's this program, away you go, take it to the gym. You know, people would fracture like crazy and I just, you know, we don't want to do any harm. Well, this podcast is for rehab clinicians, so a lot of physical therapists and people who are

[00:16:20] experts in rehab, so it sounds like the perfect people to observe these things. So what are the implications for PTs from other rehab professionals from this study? What do you want them to take away? The primary message is you don't need to be really conservative with bone and muscle conditions. People are probably not as fragile as you think they are, even if they have a diagnosis of osteopenia

[00:16:51] osteoporosis. But if you are going to apply high intensity resistance and impact training program, you need to be well trained. You need to know what you're doing and you need to supervise and you need to make sure that the conversation you're having with your clients is, I'm not giving you a program to do at home. This is a program that you're going to do with me and you need to supervise.

[00:17:17] And this is a program for life because bone is a use of or lose of tissue. So if you stop doing it, you're going to lose the bone. So this is absolutely a commitment to your bone health. You're taking this on and we're going to get to know each other very well. And, you know, it's a not to plug the Onero program, but the reason why we set the Onero program up is for exactly this

[00:17:43] reason so that physios who don't really have a strong background in exercise can get trained in the Onero program and learn how to deliver it safely. Something I wanted to touch on too about the Liftmore trial that was really great. Not only, you know, we focus on the bone mineral density improvements, but obviously one of the biggest things we're trying to do is reduce falls, right? And so can you talk about the strength improvements

[00:18:12] that we saw or that you saw in the Liftmore trial? Yeah, that was great. Probably not surprising to anyone who's done muscle training with older people. They respond beautifully. There's nothing about old muscle that stops it from responding to training. And even if they don't grow a lot of muscle, it is actually slightly surprising to me that people don't grow more muscle when they're lifting really heavy, but their muscles get much

[00:18:41] stronger. So the function is what's improving. So leg extensor strength and back extensor strength both improved something like 30%. So it was this massive improvement. And the cool thing about the back extensor strength improvement is the effect that had on people's posture. So normally when you're doing a clinical trial, you measure height and weight just because that's giving you a sense of what

[00:19:05] your study population is, you know, how big and how wide they are. Well, when you get a change in height from a group of 65-year-old women, that's what makes you really stop and go, wait, height wasn't even an outcome measure, but actually they did grow. Well, they didn't grow, but they're just standing up straighter and this is because their posture improved. So that was an outcome that was somewhat

[00:19:31] unexpected, well, unexpected, but not surprising, I suppose, but really valued. The other outcomes, things like vertical jumps, so they got some increased their power, timed up and go and sit to stand, all of those things improved. We loaded these women and they also like, they fell from a height a little bit to get some impact in when they were doing their jumping chin-ups. They did some pretty tough exercises to make them stronger and have some ridiculous outcomes.

[00:20:01] So are there any other things that you want to highlight? I suppose just as an extension of Liftmore, because in the Liftmore and the Liftmore for Men trial, we were, as I said before, testing feasibility. So we wanted this to be brief so that there was the least burden for people. It would be easy for them to manage each week. So it was just the four exercises and they did get these great outcomes in risk factors for falls. When we rolled the

[00:20:31] program out into O'Neara, we added in balance and mobility and that makes it a 45-minute program. The reason I did that is because I've started looking more into the falls literature. That is a messy research space because nobody ever tests the same thing twice in the same population for the same amount

[00:20:54] of time. And so it's the only way that the falls folks have been able to come up with a prescription that should reduce falls is to do these whopping great meta-analyses, putting together a whole bunch of studies that have all done slightly different things. And they've sort of done meta-aggressions and come up

[00:21:16] with figures of what the minimum is you need to do to get an effect. And ultimately, we know that you need about two hours a week of high challenge balance training to actually have an impact on falls. And you have to do that. Some say 12 weeks, some say six months. So the reason I inserted those balance

[00:21:43] training exercises is because this is a way to at least get some of that two hours of very targeted high challenge exercise into these people's week. And these are things that they can do by themselves, as long as they've got a couch near them so they can catch themselves if they go to fall. We really need to teach people that falls training, balance training, that's what they should be doing

[00:22:07] a lot of at home. So that's sort of another take home for me. I didn't realize just how much training you needed to do to have any kind of impact on preventing falls. Such an intractable problem. Falls have well outstripped car crashes for injurious admissions in hospitals. You know, it's just,

[00:22:30] it's a, this is where our aging population is. This is one of the biggest burdens, health burdens. So even though I'm slightly obsessed with bone and that's where all my energy is, if we're trying to prevent fracture, we really do need to focus on falls. Arterbeck, thank you so much for your time, for the work that you've done, for your knowledge, expertise, and willingness to come on the show and share it with all of our listeners. My pleasure. Love talking about this stuff.

[00:22:58] All right. One last big thank you to Dr. Beck for coming onto the show. And as always, we want to thank you for listening to JOSPT Insights. Thanks for listening to this episode of JOSPT Insights. For more discussion of the issues in musculoskeletal rehabilitation that are relevant to your practice, subscribe to JOSPT Insights

[00:23:21] on Apple Podcasts, Spotify, TuneIn, Stitcher, Google, or your favorite podcast app. If you like JOSPT Insights, help others find us. Tell your friends and colleagues and rate and review us. To keep up to date with all the latest JOSPT content, be sure to follow us on Twitter, we're at JOSPT, and Facebook, we're JOSPT Official. Talk with you next time.