Women’s Health On Demand Seminar

(upbeat music) – [Dr. Kaufmann] Tonight I would like to talk about menopause and also part of the program
is about osteoporosis. I would also like to welcome the two gentlemen that are here tonight. Thank you for coming. And especially the man
with the Muhlenberg shirt because I went to Muhlenberg. (crowd laughs) So menopause. Next slide, please. It’s really just halftime. Most of the things that women today are aware of commonly about menopause are stories from a generation
or two generations ago. And they really don’t apply anymore. A woman today who reaches the age of 50 who has not heart disease or cancer has a life expectancy of 93. And that’s today. You can imagine what the future will hold. So we must be able to make
the second half of life as productive as possible. And that means not only the structure but the brain and the parts of life that make life meaningful not only for ourselves but
for your extended families. Next slide, please. What is menopause? Well, menopause is a long process. It’s not an overnight thing. As menopause approaches, the ovaries make less estrogen hormone and less progesterone hormone and less testosterone hormone. We’ll actually talk about all three. The definition of being post-menopausal is once there’s no period for 12 months, a woman is considered post-menopausal. And really all that means is
once that definition pertains, pregnancy is not possible. So contraception, if that is chosen to be used by the couple, no longer is necessary when there’s been no menstrual
period for 12 months. The median age for menopause is 52 years. And actually, that’s been going up over the past few decades. It had been in the late 40s when I was in my training. And now it’s at about age 52. I had talked about three hormones. They’re estrogen, we
all know what that is. There’s progesterone. Progesterone is the hormone that makes the uterus receptive for the growing placenta,
the growing baby. And testosterone. And testosterone is a male hormone. You all know that. But testosterone is what
causes sexual interest in all human beings, men and women. And the decline of testosterone at the time of menopause is what causes decreased libido or sexual interest. That, unfortunately, we don’t
have a good supplement for. We obviously have
supplements for the estrogen. And progesterone is only
necessary in some people. We can talk about that if you wish to. Next slide, please. So decreased estrogen levels are important in several ways. One is for the bone. And another is for the female genital structures. We’ll talk about the bone first. What happens with
decreased estrogen levels is that the cells that remodel bone and take down old bone are unimpeded, but the cells that make new bone are not stimulated as much, which is why estrogen, your own endogenous estrogen, of course, prior to menopause makes the bone mineral density higher than it is after menopause. And there’s always a decline
with aging and with menopause. Other things that help prevent bone loss from occurring as rapidly are calcium intake. The recommendation on that, Dr. Chiappetta of course will
be talking about in a while. But usually it’s best taken
with food twice a day. Vitamin D supplements have
become much more important than we ever thought they were. When I was in training, we were taught that you could overdose on four vitamins, A, D, E, and K. And actually, we’re finding out that that is not true with vitamin D. And vitamin D supplementation
is very important with respect to using the calcium to put it into bone. But we’re also finding that probably vitamin D supplementation
is very important to reduce certain cancers,
in both men and women. One of the people that I know who goes out in the sun frequently, eats cheese and milk and should have a very
high vitamin D level had the lowest vitamin D
level I have ever seen. And that person was me. So I have taken mega doses of vitamin D up to the point of 50,000
units a week for six weeks followed by now 2,000 units every day. And in the common supplements, there’s usually only 500
units, sometimes 1,000. So don’t be afraid to take your vitamin D. It’s quite necessary. Hormone therapy is a very long topic. It’s a topic that is not really scary. It’s a topic that a lot of people think is scary and something to avoid at all costs. Not true. The data are there. The data were terribly misinterpreted, misunderstood by the lay press. But that’s a very long conversation. Suffice it to say that if people have been taking hormone therapy in approved doses, in the proper way, it’s nothing scary at all. And I can talk about that
if there are questions. And weight-bearing exercise. Weight-bearing exercise, such as walking or walking
especially with hand weights or other resistive type of exercises, very important to maintain bone structure. Give another slack. So menopausal symptoms, hot flashes, decreased libido, vaginal dryness, bone loss. We’ve talked somewhat about bone loss. Dr. Chiappetta will of course
talk much more about that. Vaginal dryness due to lack of estrogen, helped very, very well,
especially by local estrogen. And the nice thing about that
is when we use it locally, intravaginally, it’s not absorbed. So that can be used
freely in a lot of people who perhaps think that they can’t, but actually, they can. Hot flashes. Hot flashes occur in most
women for several years. And most of the time then tend to wane after three to five years. And in most women they
do stop at some point, at some point. But that’s different for different people. Do hot flashes need to be treated? You have to tell me. A woman who says they’re a nuisance, need no treatment at all. A woman who says “I’m up four
to six times every night,” “My sleep is impaired,” “I can’t function in the daytime,” that’s a woman that should think about treating the hot flashes. Different for different people. Decreased libido, sexual interest. We thought we had a supplement. And unfortunately, back
about six months ago when the code was broken, it was not found to work. So more work is going into it. The supplements that are present today, unfortunately the ones that work cause weight gain, hair growth, hair loss in different places. And they’re really rather unpleasant. So I can’t tell you we have a
good solution for that today. But if anybody would like to talk about any of these topics, ’cause I think that’s my last slide, I’ll be happy to answer any questions. – [Woman] I’m on a hormone therapy that takes the estrogen out of my body. And I always wondered why no one ever really talked to me about like vitamin D. It’s related to cancer. – Are you on Tamoxifen? – [Woman] I was on that but I’ve had very bad bone side effects. – [Dr. Kaufmann] And now the next one. – [Woman] I’m on Premarin. – [Dr. Kaufmann] Yeah, yeah. The problem with those medicines is they really do work. They work very, very well for
what we want then to work for. But they really do cause
bone demineralization. And it’s not something
that just simple vitamin D supplementation is going
to do anything about. With those medicines, other
medicines are necessary, the Arimidex, the Femara. They’re good medicines,
but they’re strong. Yeah. Anything else? – [Woman] But I mean, my question is– – [Dr. Kaufmann] I’m sorry. – [Woman] Should I be on or is that a one-to-one
doctor patient thing? Should I be on supplements for bone loss? – With not knowing exactly
what you’re taking, not knowing exactly your
dose and your history, it’s not possible for me
to give an educated answer. – [Woman] Right. – To what you should be
doing with your medicine. Of course you should talk
with your provider about that. But you might want to say I have heart the following tonight, and tell me what you think. – [Woman] Okay.- [Dr. Kaufmann] Exactly. – [Woman] Thank you. – Yes? – [Woman] How do you know the difference between the menopausal symptoms and thyroid? – [Dr. Kaufmann] That’s
a very good question. – [Woman] Because they seem a lot alike. – [Dr. Kaufmann] And they are. It’s funny. Thyroid disease can be overactive, underactive, and normoactive
in the same person over an extended period of time. So you can have all the symptoms of either over or underactive. But the heat intolerance, the sweating, the inability to focus
with thyroid disease is very, very similar. And that’s why blood testing sometimes is very necessary, to
answer that question. – [Woman] Even if it’s, the numbers are normal? – The numbers are normal,
with the thyroid testing? – [Woman] Yeah. – I don’t know what
question you’re asking me. If the thyroid tests are normal… – [Woman] Right. – And? – [Woman] Well, see, the
thing is, is I’ve seen like, like on public TV,
they’ve put on stuff about different issues, medical issues. And they’ve talked about even though your numbers
can be totally normal, you could still have thyroid issues. Because certain things
aren’t always tested. They usually just test, what
is it, your T3, T4, and TSH. – Correct. And I don’t feel expert enough to comment on the thyroid issues. If I have a question about that, I am consulting an endocrinologist. I hate to cop out like that, but– – [Woman] No, that’s fine, that’s fine. I understand. – Yeah, with normal testing, then what I normally do is say, thyroid studies are normal. We suspect you’re menopausal. You’re having symptoms. Let’s treat that, see what happens. And then if that’s not satisfactory, then we go to the endocrinologist. – Hello, my name is Dr. Chiappetta. And I am a rheumatologist
at Coordinated Health. So I’m going to be
talking to you basically about the treatment options
for osteoporosis at this point. When we talk about osteoporosis, as we know, it’s basically diagnosed by, at this time, a bone density test. So right now when we
talk about treatments, we’re looking at
something called a T score or less than usually negative 2.5. And if any of you had a bone density test, these numbers may be familiar to you. Or we’re looking at
something called osteopenia with significant risk factors
in order to treat this. And risk factors do include
family history of osteoporosis and also certain medications
that can actually cause further bone or
accelerated bone loss. So when we talk about the
treatment for osteoporosis, typically we start with the
non-pharmacologic therapy. And calcium and vitamin
D always comes to mind first of all as initial treatment. Now, I do recommend this in every woman, whether you do have osteoporosis or not to be on calcium and vitamin D. And the recommended doses
do differ based on your age and based whether you are
post-menopausal or not. Typically a pre-menopausal woman should be getting about 1,000
milligrams of calcium a day. With vitamin D, and the
recommendations do vary again, between 800 international units to 1,000 units a day. A lot of times we probably are underdosing ourselves
in the United States, but those are the recommendations. Post-menopausal women,
anywhere between 1200 and 1500 milligrams of
calcium a day is recommended. And when we recommend taking this, we do recommend over-the-counter drugs. Usually the doses of the calcium are between 500 and 600
milligrams a capsule. And they should be divided. We find that taking
more than 600 milligrams of calcium at one point, you’re not going to absorb most of that. So if you’re taking like
two tablets at once, you’re not going to get the efficacy. So we really recommend
splitting those doses up. So really every woman should be on some sort of
supplementation at this point. Now, diet as a means to
help with osteoporosis. When we say diet, it’s
to avoid certain foods. Not many foods actually build up bone, and that hasn’t really been studied. But foods to avoid are
your caffeinated beverages, your colas, your dark color colas, coffee, iced tea. And we recommend no more than
two caffeinated beverages at one day basically. Anything more than two
does lead to bone loss. So you can take two, no more than that. Diet things also would
be alcohol consumption. We find that greater than two drinks a day does lead to bone loss. And that is an additive
effect over many years. So, again, alcohol use, caffeine use should really be, you know, kind of minimized to
prevent further bone loss. Exercise, this is a big thing
that everyone always asks me, when, you know, can I
treat my osteoporosis with just exercising? And it is a minimal, minimal
effect on bone strength. The basic effect of exercise is to strengthen the muscles and to strengthen
everything around the bone so you don’t really fall. Does it really increase your bone density when you get a bone density test? Not that much, but it is important basically for muscle tone and to prevent future falls. And that’s why we really
encourage the use of exercise. And then smoking. Smoking is probably
your biggest risk factor for osteoporosis, as well
as many other things. So every patient that I have that comes in for evaluation of osteoporosis,
if they’re smoking, they really need to really
concentrate on stopping that because it does lead to
accelerated bone loss. Basically now we look
at who our candidates for therapy could be. Not everybody, even though they may have some bone loss, is a candidate. One of the new basic tools we use is something called a FRAX score. And it’s F-R-A-X score. And it basically shows
your risk for a fracture based on your age, your bone density test, whether you are on steroids, whether you have rheumatoid arthritis. It’s a poll list. And you put it into the computer. And it gives you a
calculated risk of 10 years whether you have a high
risk of fracturing or not. And based on that we could treat. Now, this comes into effect a lot of times with women who I have who
are around 50, 55 years old who get a bone density test
that shows osteoporosis but yet a 55-year-old female
is not at that high of a risk without any other risk
factors of fracturing. She’s in good health. She exercises, so it’s
not really much of a risk. So someone like that, even
though their bone density may show some osteoporosis, I may not treat based on this calculation. But then again, an 80-year-old woman who has maybe something called osteopenia, which is not quite osteoporosis, but is a smoker, who has
a strong family history, who’s on steroids should be
a perfect candidate to treat. So it’s not just based on
your bone density test. And that’s kind of a misconception. We’re now going basically
to this whole kind of fracture risk assessment. And that’s what this fracture, this FRAX score actually shows. So we’ll go to the next one. But let’s say we do decide to
do therapy for osteoporosis. What do we have to offer? Well, the most common drugs, and the ones that everybody
probably has heard of, they’re on TV and everything, is your bisphosphonate drugs, the first one being Fosamax. And now that Fosamax
actually went off patent, it is generic, and that was as
of I think two years ago now, February of two years ago. And Alendronate is the generic form. And that’s what’s available right now. So you can’t get actual, the
brand name Fosamax anymore. But Alendronate is one of the medications. You can do it a daily
dose or the weekly dose. Now, the problem with all
of this class of drugs, the oral forms of them, is that you have to take the
pill on an empty stomach. You have to wait approximately
they say a half hour, really an hour you should be waiting before eating any other,
taking any other medications, eating or even drinking. You only can take it
with one glass of water. So because of these restrictions
with taking this medicine, the daily dose is really
not that convenient to do this every single morning. So the weekly dose is more efficacious and, well more easy. And the efficacy is really the same. So most people do the weekly
dose of Fosamax or Alendronate. Another one is called Risedronate or the other name is Actonel. And the newer preparation of that is something called Atelvia. The difference between the two, you could do either weekly, every day, or even as a monthly dose,
I forgot to put up there. But the difference between the two is Actonel you have to, again,
eat on an empty stomach. The newer one, the Atelvia, which is basically the same medicine, you could take with food. So this is a kind of nicer option now because a lot of people
take thyroid medications which you also have to
take on an empty stomach and then which one do you
take first and everything. But at least this one
will give you an option. You could take this with food. Another one is Boniva. Boniva comes in two forms. It comes in a pill form and it comes through an intravenous form. So the pill form is a
once-a-month medication. The IV form is every three months you would go and get this infused in you. The infusion of Boniva takes
about five minutes tops. It’s really just a push. So really, you know,
by the time you’re in, they take your blood pressure, it’s about five, 10
minutes you’re in the place and you could leave. The last one, the most
recent one to get approval is something called Reclast. Reclast is a once-a-year medication in this group of meds. It’s five milligrams every year. It was initially used in cancer patients or people who had high calcium levels due to chemotherapy. And they then saw benefits
with this medication for reducing osteoporosis ’cause it was in the same kind of class. And then it got the
approval for osteoporosis. It’s used every year. And recent studies have shown this drug being used for about three years in a row and then taking a little
bit of a break from it, and then reintroducing it if need be. But those are basically our options in the class of what we call
the bisphosphonate meds. Now, what are the adverse effects? Because these are also the drugs that have been studied the most, and these are the ones that have gotten the big press of what could go on. Number one is esophagitis. And that’s basically from
the pills that you take. Fosamax, Actonel, Boniva, the pill form can cause reflux symptoms. It can irritate and really cause problems with the esophagus, called esophagitis. And it is a huge limiting
factor to these medications. So somebody who comes in with a history of bad reflux disease, this is not the option really for them ’cause it really will exacerbate that. What else can you get? With the IV forms, like
the once-a-year one and the Boniva every three months, flu-like illnesses can definitely happen. So people a few days after the infusion feel really achy, really tired. You can get low-grade fevers with it. They also can lower the calcium levels. And what that causes is
severe muscle cramping. And I have heard this happen. So it’s very important that if you do get one of the IV forms is to
maintain your calcium intake and take it really regularly
that week of the infusion because it can lead to
severe muscle cramps. Now, both, both the oral
form and the IV form can cause musculoskeletal pain. And I have seen this with
the oral pills especially causing chest pain with
the first few doses. Muscle pain, joint pain. I know my mother had this, and she took the once-a-month Actonel and was like, what’s going on? I feel like I’m having a heart attack. And it was the med. It is self-limiting,
meaning after a few doses, it does go away. But it can be a problem for patients. And the biggest things that
people have heard about in the news is the
osteonecrosis of the jaw, the jaw problems with these medications and the hip fractures, these spontaneous hip fractures. And everybody is like, well, why would you get a hip fracture if it’s supposed to help
reduce hip fractures? They find that with these medications more than really five to 10 years of use, it actually suppresses the
bone enough from eating away that you’re not actually
building good bone. And the way to think about this is that everybody as you walk every day you do do microfractures to your bone. And we have cells that
come along and kind of clean that bone out and
take away the dead bone. These are the same cells that
are overactive in osteoporosis and they clean too much
out in osteoporosis. But if we suppress that completely, you make new bone on top
of kind irregular bone, and you have a high chance
of fracturing over time. So the new recommendations basically, and this is not, you
know, through the board, but it’s really to kind
of go on these meds for about five years, take a drug holiday, take a few years off. And they’re finding that doing that may reduce the risk of these
potential complications. So they do happen. I’ve seen it happen in three people, three of my patients already,
the spontaneous fractures. And the only thing I could attribute it to is the Fosamax that they were on. And one was on, actually all three, one-week Fosamax at that point. So it’s something to consider. It’s something to, you know, keep in mind. Other potential options, are the SERMs or the selective
estrogen receptor molecules. And this is something called Evista. It’s a sister drug to Tamoxifen. Tamoxifen, which is the breast cancer, you know, drug to treat, it’s not indicated for osteoporosis, but it’s kind of a
sister drug of Evista is. The good thing with Evista is it does help lower the risk of fracture in the spine. The data for hip fracture reduction is not really quite there. So I do recommend this for women who are going through basically
my post-menopausal women who have osteoporosis, their hips look pretty good. Their spine is kind of, uh, so-so. This would be a good drug for them. And it would avoid the
potential complications of the Fosamax, the Actonel, and Boniva. They don’t see those hip fractures or anything with this one. (indistinct) also is nice. There was a trial that came out that showed that this does also lower the risk of breast cancer. So someone who is a high
risk of breast cancer, this may be a good drug for them. It does, though, increase
your risk of blood clots. And it can also induce hot flashes. So those are your two side effects. So again, it’s not a
completely benign drug. Estrogen and progesterone. This is no longer first-line therapy based on the woman’s health initiative and the health study
that came out about 2002. Basically they said
this is not first-line. We have better drugs, because there were potential complications with long-term estrogen and progesterone use. But may be good for
somebody who can’t tolerate the other drugs and has
post-menopausal symptoms, such as hot flashes, this may
be a good option for them. Again, estrogen, just like Evista, has been shown to reduce
the spinal fractures better than hip fractures, so. Another one, and I don’t
really use this much, is Calcitone in nasal spray. But there is a nasal spray that you can use for osteoporosis. It’s one spray in a nostril and then you go to the
other nostril the second day and kind of go back and forth. It can cause nosebleeds and I have seen that
happen with this drug. It has a weak effect on bone health, so it’s not really great. But it’s good for helping acute pain from vertebral fractures. And this is why I do use it. People who have a compression
fracture from osteoporosis, you can use this to help with the pain for the first few weeks. And it does help. It’s not 100%, but it does
help alleviate it a little bit. The next one is the parathyroid hormone. This is now we’re getting into the kind of more interesting and newer things. The one it’s called Forteo, and you may have heard of this drug. It’s the only anabolic agent. So what does that mean for osteoporosis? It’s the only agent that we have out there that actually builds bone. The rest of the drugs, including
Fosamax, Actonel, Boniva, they never build bone. They kind of stop the loss of bone. But this one actually builds it. And it was a kind of a cool concept. What they did is they looked at something called the parathyroid hormone, the same hormone that
actually at high levels when you have hyperparathyroidism,
causes osteoporosis, but they find that if you give
it in short bursts every day and it only lasts in the
system for a couple of hours, it actually induces cells that build bone. If it’s in the system longer than that, you actually recruit the
cells that eat away the bone. So these short bursts on a daily basis actually help promote bone growth. It is an injection. That’s one limiting factor. Some people cannot give themselves a shot. And they do give themselves
little shots here. It’s given for two years. And after two years, we put you on one of the other
medications to maintain it. And that would be like going
on Reclast or Fosamax or so. What is the problem with this medication? Well, the biggest thing
that people worry about, and knock on wood I have never seen it, but is something called an osteosarcoma, which is a cancer of the bone. Now, this drug has been out for about 10, 11 years or so and studies have been out. The incidence of this osteosarcoma is about the same as
the general population on people on this drug. So they do not see an increased incidence in women taking this. They did see it in the trials in rats. And the rats were given
super therapeutic doses for their body size. They were given a human sized dose for a tiny body size, which they think may
have contributed to it. They didn’t see it until
they were on the drug for about four to five years. So again, we only use it two years. They’re using it longer. And rats have also a different kind of skeleton too than humans. They have more of a skeleton like a child that’s in a, kind of an
overproductive state. It’s constantly turning over. And we do know children have a higher risk of bone cancer than adults do. So we’re thinking that
may be a risk factor too. But it’s something to be mentioned. Everybody is always very
cautious about taking this because of that incidence. Okay, Lynn, go to the next one. And the last one I do want to talk about is the medicine called Prolia. Prolia is the newest one out for the indication of osteoporosis. It has been really,
really good to decrease both hip and spinal fractures. This is also a subcutaneous injection. But it’s done in the physician’s office. It’s every six months
instead of being every day. You come in twice a year to get this done, takes a few seconds and it’s done. What this is is actually an antibody that kind of binds to the cells to stop their communication
and stop the development of the cells that will eat away bone. What they found in some trials, and this is what the limiting
factor for some people are, but that it hasn’t been
found in all the trials, is that it may increase
your risk of infection and maybe increase your risk of cancer. It’s been disproven in trials, though. It’s not across the board. So some saw an increased risk
of like flu-like illnesses and urinary tract
infections and pneumonia. Some cancer risk went up, but again, it has not
been continuously proven. So it does work pretty well. And what’s nice is that this one is not excreted by the kidneys. So so far it’s safe in
people with kidney problems, which is also why we can’t give a lot of other medications
for osteoporosis because we can’t use
them in kidney disease. So this would be an option
for people with that. But I think that’s, I think that’s it. So those are our choices for treatment. Is there any questions
about medications or… Yep. – [Woman] I’ve been
taking osteo (indisctint) Evista for years. And I have had three fractures since then. – While you’re on Evista? – [Woman] Yeah. And then I had a bone density test, and they said I have osteoporosis and arthritis in my back. My doctor put me on Fosamax. And I couldn’t take it because it start, I had trouble swallowing pills. – Right. – [Woman] Because of my esophagus. So now they’re suggesting
that I go on Reclast. And I’m a little afraid to go on it. – [Dr. Chiappetta] Actually, the Reclast is a very reasonable option at this point. Obviously the Evista
is not working for you. And the fact that you’ve– – [Woman] He told me to
keep taking Evista anyway. – You can. There is studies with combination therapy that it may like augment
and may be better for you. Is there any other reason
you’re taking Evista, like is there a history of
breast cancer in the family or you’re at risk factors
for that or anything? – [Woman] No. – No, I mean, necessarily you can do both. It’s not going to harm anything. You may not have to ’cause the
data with Reclast by itself is actually pretty good
for fracture prevention. And Reclast does work great
for both spine and hip, while Evista you’re really just getting some spinal protection with it. So you don’t have to take both of them. I know some physicians do. And there’s nothing wrong with it. But you don’t have to. Now, Reclast is great
because it’s convenient. You take it for about three years. Again, this new study
came out, three years. And you can take a three year holiday. And they’ve found that
people taking this drug, Reclast, six years continuously versus three years and
stopping three years had the same bone density at the end. There was no change. So it’s good. It actually it’s nice
that you could do that. Take a break, so those risk
factors for hip fractures won’t be there, at least
we think so right now. That may change, who knows, in a few years they may see something happen, but, yeah. – [Woman] Thank you. – Yep. – [Woman] Are there
different bone density tests? I only see the machine where
you put your heel in and– – [Dr. Chiappetta] Yes,
that’s actually called the Pixi or a heel scan. That’s not what your criteria
for osteoporosis is based on. That’s good almost as a screening test to say whether it’s abnormal or normal. That’s basically all it tells you. If it’s abnormal, then
your insurance will pay for a full-blown DEXA scan. So a lot of times
insurances won’t pay for it until the age of 65 unless you have risk factors
for osteoporosis, so– – [Woman] DEXA scan. – A DEXA scan, that’s the full one. That’s where you get the spine, the hip. (Woman talking indistinctly) Right, they do, it depends
on which DEXA scan too because there are many different models. But they’ll do the spine. They could do one or two hips based on the bone density machine. And they do your forearm. And that’s pretty, a good assessment of potential fracture risk for different areas of bone
and different types of bone. But a lot of insurances won’t pay for it unless you’re 65. And they’ll start off with this heel scan. They’ll pay for that. And then if that’s abnormal, then they’ll pay for the DEXA scan. – [Woman] There’s just one
type of heel scan, right? – Yeah, they’re basically the same. There’s probably different
makes and everything, but yeah. – Hi, everybody, my
name is Melissa Pittas. I’m a therapist here at Coordinated. What I’d like to briefly
just touch on today is what we can offer here at Coordinated in our outpatient physical therapy program for patients who are at risk for falls, osteoporosis, or osteopenia
or arthritis. (chuckles) Basically, the osteoporosis program that we’ve developed
here is gonna involve, it’s an individualized program for every patient that
comes through the door. But generally what we do is
we start with an evaluation. And that would include a general
range of motion assessment of arms, legs, back, pretty
much throughout the body. We do a strength assessment, check flexibility of the
muscles, of the joints. We check your endurance
to see how we think you’d be able to tolerate
an exercise program which helps us decide what kind of program we could design for you. The other thing we’d talk about, the two big ones I love to talk about are home safety management, fall prevention, and
also postural alignment. Posture is one of the really
big things that we do here. I’m sort of the posture guru, posture nag. Pretty much every patient that sees me whether they’re coming
for a knee, an ankle, a back, a neck, or whatever, is gonna get some sort of posture lecture if they come to see me because I’m very, very big on posture. When you’re five feet tall,
you stand up straight, so (laughs) Okay, basically with the education, I think we’ve already touched on osteoporosis and osteopenia. So we know the osteopenia is weak or weakened bones whereas
osteoporosis is brittle bones which increases your
risk for the fractures. We talked about the
risk fractures as well. But with the posture, as you can see, the postural changes
just in this slide here, what happens as we get older, I know a lot of people have
come to me in the past. They’ve come to me with this diagnosis or just with back pain
or an arthritis diagnosis and they say, well,
I’ve also been diagnosed with osteopenia or osteoporosis. That means that I’m gonna shrink and I’m going to look like
this in a couple of years. That’s where we come in. That diagnosis doesn’t automatically mean that that’s what’s gonna happen. What we like to do is prevention. We have Dr. Chiappetta
talked about the medicines. But as far as what we can do is we’ll go in, we’ll do the evaluation. We’ll develop an exercise program and a postural awareness program as well. We’ll talk about how to
strengthen the muscles around the arthritic joints and the osteopenic or osteoporotic joints. What we want to do is you can only strengthen the bone so much. But you want to strengthen
the tissues around the bones. You want to make sure that the muscles, the ligaments around
those osteoporotic joints are as strong and stable as they can be because they will help
to support those joints, which also will help to decrease the risks of the falls and also
decrease the risks of injuries in the event that you do have a fall. So we would talk about doing different types of
strength training exercise, which would include like light weights. What weight training will do is causes the muscles to contract. Those contractions cause the tendons, which attach the muscles
to the bone, to contract, and that actually causes
some stresses on the bone which help to strengthen
the bones a little bit. The other thing is the walking, which Dr. Kaufmann touched on. We’ll talk about developing
like a walking program, which we would do here. We could do it on
equipment, on the treadmill. Talk about how you can
do a walking program around your development
or on walking trails. There’s some wonderful walking
trails around the valley, which is a great way to get outside and get your vitamin D as well. So the other thing we would develop is posture exercises. And these are pretty simple exercises. They’re not intense exercises. Most of them we can have
patients do in chair. So we have patients who can’t
stand or walk very well. We adapt the program and modify it so that you can do the
exercises in the chair. That way if you’re taking a car ride or doing those bus trips to the casinos, you guys can do your strengthening
and postural exercises while you’re sitting there on the bus. Balance is another one. If we have postural
changes as we get older, throughout our lives, and we do tend to come
forward a little bit, we can do a posture assessment. We can help to correct that because what does happen is if we do have poor posture and we do start to come forward, our center of gravity will shift, which in turn is gonna affect our balance and increase our risk for falls. So we would address that as well. And then we would transition
that into the home. What I would do with you
in a few simple sessions is we maybe talk about
your living arrangements. Do you have stairs? Do you have carpeting? Do you have hardwood floors? How your house is set up. And we would talk about the safest things that you would have in your house, like good lighting, rubber stops on stairs
that aren’t carpeted. We would talk about, you know, clearing a room, keeping things
away so you wouldn’t trip, keeping clear of clutter,
things like that. We would talk about, the big
thing I like to talk about is making beds and laundry. These are two very difficult activities if you have back pain or if
you have a weakened back. So we would talk about
safer ways to do that, more efficient ways to do that, you know, depending on how your
washer and dryer are set up, if they’re stackable,
if they’re side by side, how the door swings out or down. And we address that whole area. So everything is individualized. Like I said, you know,
we’ll do the evaluation. We have our general exercises that we do. We put together a nice,
condensed program for you. We usually do it in a few sessions. We can usually do it
in about four sessions, sometimes two sessions. But insurance covers it, and we can do it for as long as it’s medically necessary for you to be there so that we can make sure that we address all the areas that we possibly can. If you would have questions
about your insurance, we have the girls over there who always make sure
they verify everything before you would come to make sure how it would be covered, if there would be a small copay or co-insurance
involved with it. But basically, we work
together with your provider, whatever doctor would like to send you. And it could be any doctor
that can send you for this. It could be Dr. Kaufmann. It could be Dr. Chiappetta. It could be your family practitioner. It could be your orthopedic surgeon. It could be a physiatrist. It could be anybody that can recommend you for this program or any
of the therapy needs that you might have. Does anybody have any questions? Oh, yeah, don’t sit like that. (crowd chuckles) When your mom always
said, sit up straight, (crowd laughs) she meant it and she was right. I have two girls at home. So I can honestly tell you my 13-year-old, who is now three inches taller than me, has probably some of the worst
posture you’ve ever seen, which is terrible. And I remind her of it
every day, but, you know. You know how that goes. Sometimes you’re fighting
a losing battle, yeah. (laughs) But are there any questions? Yes. – [Woman] At the age
of 86, is that too old to start a program like that? – [Melissa] Oh, you’re never too old. – [Woman] No? – [Melissa] I have a couple of, I had one woman who was
91, another one who was 92. And I also just did some
balance training with a woman prior to coming here who was 96. – [Woman] Because my mom’s 86, and I think she could use a program. – Absolutely. And like I said, I’ve had people
come in with that question. I’ve had them come in
with resistance, you know. And usually, their children
would come with them, like in this case, you know, if you would want, you would come with her and, you know, sit in
and ’cause a lot of ’em sometimes are, but I’m too old for this, there’s no hope for me. There’s always something that we can do. Everything is modified. Anything that we do, any exercise, they’re very, very gentle exercises. They’re very easy. There’s no special equipment. The only thing is maybe just
some bands and things like that which, you know, we’d provide for you. There’s nothing else special
that she would have to do. We don’t need any big space
or anything like that. So, sure, any kind of education, any kind of simple things that
I could give her, absolutely. – [Woman] That would have
to be referred by who? – She would need a prescription, yes, from, like a said, a family
physician or a specialist. It doesn’t really matter. And it really would
just have to basically, it could just say physical
therapy, eval and treat, with a diagnosis of, it could be pain, it could be osteoporosis, it could be abnormal gait, balance issues, you know, anything like that, as long as it has a diagnosis on it and it’s a prescription
for physical therapy, that would be fine. And it’s dated and signed by the doctor. (laughs) That’s always a help. Anything else? Yes. – [Woman] I can’t walk very far. – Okay. – [Woman] And I can’t stand for very long. And I’ve tried doing the walking. And it just doesn’t work. – [Melissa] Right. – [Woman] So how would I
get into a walking program? – [Melissa] Well, you
might not necessarily get into a walking program. But we can still do a
weight-bearing program for you, which would include,
as opposed to walking, we would do things, like in the clinic, we would do it by the parallel bars. At home I can show you
how you would do it, like at your tabletop or counter where you can hold on for safety. And you can still do plenty
of weight-bearing exercises, just not actually, you know,
walking for long distances. Or we could figure out, you know, test you out and see how
you do on a treadmill and see how long you actually can walk. – [Woman] Well, I have
a treadmill at home. And I tried it a couple of times. And I didn’t get very far. – Is it cardiac? Is it weakness in your legs or what? – [Woman] Knees. – It’s weakness in your legs. – [Woman] Legs too. – Oh, well, I can help you with that. (crowd laughs) We’ll address that. That goes part of the strength assessment. So we’ll, you know, part of this is not just doing the osteoporosis program. We need to find out, you know, that’s why we do a whole evaluation because it’s gonna involve everything. That’s why I’m gonna test
the strength of your arms. I’m gonna test the strength of your legs. I’m gonna test the strength of everything so that we can see, well, you know, you got some, you know, you might be at a high risk for falls or, you know, you have osteo, you said
you had osteoporosis or even osteopenia,
arthritis in your back. You know, if weakness in
the legs is contributing to balance issues or maybe
it’s the way you walk. Maybe the weakness in the leg is affecting how you walk, you know, we kinda take it back a step. And instead of going
right into those things, we would address the strength issues and address any flexibility or lack of range of motion issues and fix those first and then go into the rest of the program. So everything that we do could, you know, it’s not just going into one thing. It’s breaking it down, finding where all the deficits are, addressing those, and then
putting that together. – [Woman] I thought maybe
the weakness to my legs was from using a cane all the time, that I (indistinct). – With a single-point cane, it gives you an extra point of balance. But it’s not gonna cause that much weak, you’re still relying on
your legs quite a bit, which you’re still full weight-bearing with a single-point cane. You just got that little extra to help you with your balance. But a single-point cane’s not
gonna make your legs weak. (upbeat music)

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