transcript

Speaker 1:
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Speaker 2:
[00:33] Welcome to You Are Not Broken, the podcast that challenges everything we've been taught about midlife, hormones, and sexuality. I'm Dr. Kelly Casperson, board certified urologist, author, and a leading voice in women's sexual and hormone health. Enjoy the show. Hey everybody, welcome back to the You Are Not Broken podcast. Very excited today to have on Lisa Moore, who is a physical therapist, who has an amazing YouTube I've been referring a lot of people to lately called Brickhouse Bones. And thank you for being here on the You Are Not Broken podcast.

Speaker 3:
[01:02] Thank you so much for the invitation. I'm really, really happy to be here.

Speaker 2:
[01:05] So a lot of people don't know physical therapists exist, which is very weird. And a lot of people, I think, assume doctors know more about the musculoskeletal system than physical therapists do. And I'm like, dude, my physical exam is amateur hour, and I'm pretty good at examining the pelvis compared to most doctors. Physical therapists, that's what it's literally graduate training in. Can you talk about your journey on how you got to be specifically in your niche?

Speaker 3:
[01:34] Oh, yeah, it was a long journey, actually. But yeah, we're all about the muscles and the bones and the bodies and the joints. And how do we help people function in real life with less pain and more confidence? And that's what I like to do. And near the last few years of my career, I was working in oncology rehab, which was such a gift to be able to help people through their cancer journey. And the science behind oncology rehab is really fascinating for, as a specialty physical therapy thing too, and just how it can really improve outcomes and everything. But many of my clients were people who were experiencing breast cancer and going through breast cancer treatment. And as part of the treatment, including the chemotherapy and the radiation as a subsequent aromatase inhibitors or estrogen suppression, they were at really significantly increased risk for osteoporosis and even a 10% increased risk for fractures over women who don't have breast cancer. So they were coming to me saying, hey, what do I need to do to protect my bones? And I didn't know. That wasn't part of my oncology rehab training. And I don't like not knowing. I knew enough to tell them to be more afraid of movement. I didn't know enough to help empower them in the right movement. So that's the deep dive into figuring it out. And along that journey, I said, hmm, I should probably get a DEXA scan and find out, right? You know, I'm not 65 yet, but I don't want to wait that long to learn this. So I had my own DEXA scan and found out, surprise, I had osteopenia as well. So this deep dive took a few years because the information out there for women is confusing and conflicting and it's muddy water. And if it was difficult for me to sort out what to do, I couldn't imagine somebody going through treatment or somebody just trying to understand what clear steps do I need to take? It was not clear at all. So that's what led me to do this. And the more I found out that there were very few people specializing in this kind of education and training, and I needed to start to make content so people could have access to free content on YouTube and begin to take steps, not be stuck in fear.

Speaker 2:
[03:34] I love that. Yeah, I think that's what I would have added to your thing of like, it's confusing. And I'm like, there's a lot of fear inducing stuff also. And I think there's also a lot of like not meeting people where they're at. So there's people who are like, they've never lifted a weight in their life. And then people are like, lift heavy. Right. And it's like, don't read the ending of the book before you read the introduction. You know, so meeting people where they're at, I think is super important. Lisa practices in Tacoma, Washington. And the YouTube is available for everybody. I think people can take your YouTube and bring it into their either sports medicine person, personal trainer, to be like, here's some exercises. You know, this person's been thinking, how do you see people using your YouTube?

Speaker 3:
[04:17] Well, YouTube is organized into playlists because exactly like you said, I have people who have never exercised before that want to learn what to do. And so we've got some of the basics that we know are helpful, protective and safe for people to do if they have low bone density. But there were people like me who were otherwise active and fit and wanted to still be able to exercise at a certain intensity but didn't want to do the wrong things or didn't want to have risky moves in their program. So I have beginner stuff, beginner balance, playlists. I have playlists that are more moderate intensity, all full body covering all the major muscle groups. And I have some other programs that are a little bit more robust along the way as well. I have a workshop. It's on my website. It's a low-cost workshop. But this is appropriate for anyone who is curious about how to manage bone density, anyone who's working with somebody to help them exercise with their low bone density. It's appropriate for both patients and exercise professionals and other rehab professionals because all the education is in there.

Speaker 2:
[05:14] I love it. What's your website?

Speaker 3:
[05:17] drlisamooredpt.com Love it.

Speaker 2:
[05:19] I have a lot of doctors, nurse practitioners, physician assistant associates, like lots of clinicians who listen to this podcast. Having you as a resource to be able to say, hey, go watch this, go start learning about this, because a lot of clinicians are like, we didn't get trained, and furthermore, we don't have the time to say, do this, don't do that. Let me show you how to do this, the importance of balance. I think, let's start with balance. I think a lot of people don't understand mobility, balance work, just understanding where your body is in a three-dimensional space. It's so underrated, the balance work, but catching yourself when you trip, right? That's balance work. It's best to train for it. The whole thing is A, don't fall, B, know how to get up once you fall.

Speaker 3:
[06:03] Yeah, 100%, yeah, balance. So when we look at some of the stats on fractures, so that's really what osteoporosis is, a risk factor for a fragility fracture, a low trauma fracture. So my number one goal of work in people is to prevent a fracture. Eighty to 90% of all fractures happen because of a fall, right? So if we want to really target one of the most important ways that almost anyone can access, it's balance exercise. And balance exercise is more than just standing on one leg when you brush your teeth.

Speaker 2:
[06:30] Okay?

Speaker 3:
[06:31] So it's not just tree pose in yoga, which is a wonderful thing.

Speaker 2:
[06:34] I love that pose. I do, too.

Speaker 3:
[06:36] But we can dynamically train balance. And that's when we fall, when we're moving and we're distracted in our head turns, when we need to step over an obstacle, when we're doing more than one thing at the same time. So we like to do dual task training with balance activities, dynamic training, which means we're perhaps doing a movement with our arms and turning our head while we're performing a balance exercise. Maybe we're putting on a jacket and stripping it up while we're performing a balance exercise. Maybe we're looking for an address on our phone while we're doing a balance exercise. These are real life things.

Speaker 2:
[07:10] That's so smart.

Speaker 3:
[07:11] And this is how people get tripped up. So if we train this, it gets better. Strength training also improves balance. Here's the secret sauce. The thing that I think is missing a lot of conversations about exercise training for fall prevention is power. Power training is strength plus speed. It's that agility, that quickness to move our body through space and prevent that fall from happening in the first place. So power training, I think, is a really important component of that comprehensive exercise plan for bone health and preventing falls and fractures.

Speaker 2:
[07:45] There's data on that too. They're looking at like, is it just your muscle size that matters? Is it your muscle strength that matters? And they're like, it's power, the ability to move something like three-dimensionally, like physics, right? Is actually, power is very strongly correlated with longevity. So it's not just like, bigger is better. You could have small, strong, powerful muscles, but I think everybody kind of gets, they think size and power are the same thing, but they're not exactly.

Speaker 3:
[08:14] Right, right. It's just that, can you move quickly? Can you respond quickly? And we think about things when we used to run up the stairs, we could do those really agility things that were easily. I can just ask someone to skip, and I can see that they're having trouble with power, because they've forgotten that little bit of explosive agility coordination.

Speaker 2:
[08:34] Oh, so I had a patient come and I have a in-body scanner. So it does body composition, muscles and lean body mass, visceral fat. And it's just like a little scale, like three or four inches off the ground. It's just a little teeny step up. So it's less than a step is, right? It's just like getting on a scale basically. And she had trouble getting on the scale and doesn't use an assist device in person. She walked in, walked out, sat down, stood up, but had trouble getting on that scale. If you see that, what are you thinking of like, we need to work on? Is that balance? Is that strength? Where would you start with her?

Speaker 3:
[09:09] Well, number one, I'm identifying a fall risk. That's absolutely identifying a fall risk. So I'm always thinking multi-components. So I would want to do an assessment of what are the areas? Is it a vision impairment? Is it limits of stability? How far they can reach? Is it a strength? So testing strength, testing range of motion, testing sensation, testing the ability to step over obstacles. What is their walking speed? How fast can they walk? So we have a timed up and go test. We have a 30 second sit to stand test. It's going to give me a measure of their lower body strength. And I want to address all of those things. I want to address functional strength, functional activity strength, which is squats, hinging, pushing, pulling. I want to address balance. So we have to start with the base of static balance, which could just be feet together holding. And then we move to dynamic balance, stepping over obstacles, working up and down a step, making that step taller and taller as we go, adding load. I always want to add load as we go. I don't care how old my client is. We want to add load and work on that muscle strength.

Speaker 2:
[10:14] Yeah, I love it. And I think a lot of people who are inactive think that their trainer or whatever is going to throw them 120 pounds on their back for a back squat on the first day. They're probably just going to start with you squatting your body weight. Or very simple stuff, right? How can you move again through time and space of like, some people are so deconditioned, we just have to start there.

Speaker 3:
[10:39] Yeah, that's actually my absolute favorite client to work with is somebody who is starting from no exercise background or experience. Because we have the principle of initial values that tells us that the people with the lowest functional capacity to start have the greatest potential to gain. And they can see it really quickly. And when they can feel and see that change in their body in just a matter of weeks, it accelerates the momentum and it keeps them consistent. They have that motivation because they can feel the change. And it's just remarkable to see happen. But it doesn't matter how low you're starting, the change and improvement can absolutely happen. It can be life-changing, literally.

Speaker 2:
[11:16] Yeah, I mean, I think about listening to the pro, the pro bodybuilders, the pro people, when they're like, it took me six months to put on another half a pound of muscle, right? Like once you're up at that level, it's like very hard to see the gains because you're so optimized. But you're right, the people with a lot to gain, it happens fast. And those people sometimes need that quick feedback to be like, oh, I'm showing up and whoa, the results are actually happening pretty darn quick. Now it's time for an ad from Midi Health, the online experts in menopause and perimenopause. If you're about to hit pause or grab a snack, give me 30 seconds here. If you've ever wondered whether what's happening in your body and brain is just in your head, it's not. Stay with me. Let's talk about what's really going on. Midlife hormone changes. This is where Midi comes in. Created by women, for women. They offer personalized treatment plans with safe FDA approved hormonal and non-hormonal options. I have so many women tell me about how they're so happy with their Midi clinicians. And they're available 24-7. And they accept insurance. It's time menopause care caught up with women. Book your virtual visit today at joinmidi.com. That's joinmidi.com.

Speaker 3:
[12:34] Yeah, those little successes are really fantastic. And it takes away, because we have this thing, we feel like we need to do it perfectly, or the perfect amount, or if we do it wrong, we're going to get hurts, we don't want to do anything at all. And really, if we can just start simply, start small, stay consistent, and see those little gains, it really leads to the momentum that creates the change we want. It keeps us independent. That's the key.

Speaker 2:
[12:57] Totally. I think most people want to be independent. If they don't want to compete on stage in a bikini competition, that's fine. Most of us don't. But we want to... I don't want my brother wiping my ass, frankly.

Speaker 3:
[13:07] Exactly. Exactly.

Speaker 2:
[13:09] You recently got back from a very large trip across the world. Give us tips for... I'm pretty good at home in my gym routine, but travel throws people off. What do you do when you travel to stay active? I mean, airplanes are horrible for musculoskeletal issues.

Speaker 3:
[13:28] Yeah. So, yeah, we just had a wonderful trip to New Zealand. It started off, so we had a little pit stop in two days in Honolulu, and we had a hotel gym. So, hotel gym is marvelous. Get up in the morning, go do a simple work. I don't do anything aggressive while I'm there. I just try to keep it simple so I'm not sore. I don't want to be extra tired, but just if I can get a hotel gym workout, great. And we'll go do a little bit of that. The rest of my trip, well, we did bring exercise bands. I didn't use them once, to be perfectly honest. But we did incredible hikes. We were very active. We were walking, we were canyoning, we were adventure capital of the world, and I was adventuring. So mostly when I'm on vacation, I don't stress. I don't because I know my routine consistently is to do this at home. I'm not the guilt police about exercise. That's not my thing. But my vacations tend to be active, whether I'm swimming or paddle boarding. I'm doing things I enjoy, and that's why I strength train on the rest of the time. So I can do those things I enjoy and I'm not sore, and I'm not getting injured and doing anything like that.

Speaker 2:
[14:26] I love that. So let's talk about a new woman comes into your practice, because I see this all the time, and this is kind of myth busting. People think osteoporosis is a fixed entity. It's just, those are my bones, that's how it is, this is how it's going to be. You know, doctors play a role in that, because we're like, we kind of discuss it like it's a fixed state. But bone is constantly changing and remodeling and listening to signals. Can you talk about kind of the myth of like, once you have it, you have it? Because people are like, what do you mean you can reverse osteoporosis?

Speaker 3:
[15:01] Absolutely. And I want to talk about what you say about the messaging to it first, because this is something I hear every single day from clients that meet me, they're asking for help. Recently, a client said, you know, I met with my doctor yesterday and talked about the osteoporosis, and I left there feeling like it was the end of my life. I was so sad and so scared. And she said, I asked about exercise and activity and working with a trainer. And she said, it's too late. She said, I felt as if my life was over and that I couldn't trust my body to do anything. We meet one time and just talk about empowerment, what you can do. She starts doing it and she's someone who wasn't exercise. She was active, like dancing and playing act, but not really exercising. Starts doing 30 minutes, twice a week of exercises from the YouTube channel. Life changing. She emails me, Lisa, you wouldn't believe it. I can go up and down the stairs multiple times and I don't even think about it. I can do my daily chores without ever questioning it. It used to be something I worried about, can I accomplish this today? Now, I don't even think about it. This is simple. But I hear this message from people who are not exercising, and I hear it from people that are triathletes, that are working out five and six days a week, and they find out they get osteoporosis, and they stop doing everything.

Speaker 2:
[16:15] Because they're afraid they're going to break something?

Speaker 3:
[16:17] That to me, yes, exactly. They feel they're not confident in their body, they're afraid of what they're going to do, they don't know what's safe and what isn't safe. And so it doesn't matter if they're experienced or not, they freeze, and that's what I'm trying to counteract. I'm trying to create that positive experience with exercise and knowing what people can do. And yes, if you have low bone density, there's certain steps we can take, and we've seen multiple studies that support. The Lift More trial is one, but there's more than other studies, not just on high intensity exercise, but also include moderate intensity exercise, that you can have a positive impact on bone density and increase bone density. And typically, the changes we may see would be somebody may go from osteoporosis to osteopenia or osteopenia back to normal bone density. We don't typically see that big jump from osteoporosis to normal.

Speaker 2:
[17:04] I've seen it though.

Speaker 3:
[17:05] Fantastic, yeah.

Speaker 2:
[17:07] I've seen it multiple times.

Speaker 3:
[17:09] Right, and when we're getting that comprehensive approach, when we're looking at medical treatments and therapies and hormone therapies and the right type of exercise and impact training for people who can do impact training, yes, bone is constantly changing remodeling, and we can absolutely see positive changes in bone density testing. And bone quality, not just bone density, but and bone quality. So bone density is how much bone you have. Bone quality is how well is that bone organized? And I like to use the analogy of a bridge. When you look at a bridge, you just see the road that goes over the water, and that's your bone density. We just see the external of the bridge and the road. When you look at the internal parts of the bridge, you see all these crosslinks and hatches, these triangles and these wires, and that's what gives the bridge the little flexibility and strength, and how the bone is organized is what helps it be more fracture proof. And bone quality in and of itself is a fracture predictor.

Speaker 2:
[18:07] Yeah, I think it's like carbon fiber, for lack of a better word, but like carbon fiber is incredibly light, but incredibly strong, right? Versus something like super rigid and brittle, it might be big and dense, but it breaks easy. And I think people don't understand that the DEXA scan is a proxy for bone strength via measuring density. And where we see this especially is in thin boned women. I'm one of them, right? So small people have smaller bones. That might be interpreted or misinterpreted as osteopenia because they're light. That doesn't mean they're not strong. Australia is ahead of us. Several countries are ahead of us in basically looking at ultrasound to measure the microarchitecture instead of just using X-ray and how well the photons go through the X-ray plate is a measure of density. So I've had DEXAs that say osteopenia, and then I get the REMS ultrasound and it says, excellent bone architecture. That is a perfect example of thin, small bone, but strong. And I think where I hope we're going to get with this, because I think it's going to freak people out to get an osteopenia diagnosis. But again, are you made of carbon fiber? Right? Or are you thin and frail? And I think, what do I hope in 10, 5 years, 10 years, these ultrasounds are coming to America. They're not that expensive. And I think that's going to be more and more. And you can get DEXA with trabecular bone score. Not all DEXA places do that. In my town, I've got two places that do DEXA. Only one does a trabecular bone score, which it measures the microarchitecture. So there's a lot to do, but I want to just educate people on that, to be like, just because you're small and might be not dense, doesn't mean it's not strong.

Speaker 3:
[19:58] Exactly. And things that can change bone quality, density may not change, but exercise can improve bone quality. Exercise, estrogen therapy, adequate vitamin C, adequate protein, that vitamin C, I meant calcium, protein, managing our blood glucose and inflammation, all of these things can help impact our bone quality.

Speaker 2:
[20:19] Totally. I think if I could get anybody to understand everything, is like the bone responds to the world around it. For example, like the International Space Station people, right, like they come back with beat up bone quality because there's nothing putting any force on their bone. They've got zero gravity, right? So like just gravity itself tells the bone, hey, be strong. You take the gravity away, their bone quality will suffer.

Speaker 3:
[20:46] Yeah, absolutely. That's why load, when we can, when we can load the body as something as simple as a farmer's carry or weighted carry is a great way to help stimulate bone growth.

Speaker 2:
[20:56] I love the farmer's carry. I feel so freaking strong. It's not complicated either. It's not like you're lunging and twisting or anything. You're just carrying something, which translates to carrying kids, carrying groceries, carrying something into the house, moving a piece of furniture. It's such a translational exercise.

Speaker 3:
[21:14] Yeah, we all try to grab every single grocery bag and get it in one trip. That's what we're training for.

Speaker 2:
[21:20] I absolutely love it. I see a lot of women who think, you know what I'm blaming? I'm blaming, remember the Got Milk campaign of like, I don't know, it was about 20 years ago now? I blame that. I could be completely wrong. But women are like, I'm taking a calcium supplement. And I'm like, that's all you're doing for your bones? Like, number one, I'm a urologist. Kidney stones happen more when you take pills of calcium instead of dietary calcium. So I'm like, I'm the urologist who's like, watch it. Women who come to see me are leaders, role models, and nurturers. They've dedicated their lives to supporting others. Often at the expense of their own self-care. This is why my passion is helping midlife women rediscover the confidence that comes with prioritizing their own health and well-being. Vaginal dryness is a painful fact of life for so many women in menopause, but it doesn't have to be yours. My first line treatment for my patients is vaginal hormones. However, I also recommend Via by Solve Wellness. Via is a non-hormonal vaginal moisturizer featuring hyaluronic acid that replenishes your body's natural moisture and is safe for daily use. To learn more about Via vaginal moisturizer by Solve Wellness, visit viaforher.com. That's V-I-A, the letter 4, her.com, where new customers get 20 percent off their first purchase. For an additional $5 off Via, use coupon code DRKELLY5. That's Drkelly5. Clinicians can request patient education materials and samples by visiting hcp.solvewellness.com. Because too much calcium at once, specifically in pill form, is a huge load of calcium on the kidneys. The kidneys will filter it and just dump it out in the pee, and that's where the kidney stone risk comes from. So food is best, like you said. But I think, again, it's like if you think just taking a calcium supplement is bone health, you're missing the other big drivers.

Speaker 3:
[23:17] Yeah, I'm not a big supplement person when it comes to that. There are a few of the basics when we look at it. We do want to make sure we want to get enough calcium, food-first approach always, and I use a food-based supplement when I need it. So that just fills the gap, and I know it's not like a calcium citrate or something like that, synthetic calcium. We want to get enough protein because bone is one-third protein by mass. We want that protein. Protein is the structure that the minerals adhere to, to give bone its flexible, strong structure. So we have to have adequate protein. If we want to build bone, you got to get enough protein, period.

Speaker 2:
[23:55] Especially like say a woman's coming in with osteopenia or osteoporosis. Are you asking her how many grams per pound of body weight? Like, are you addressing that? Because I think a lot of women, certainly like my women in their 70s, so they were around before the 90s, is like thinner as a sign of beauty, like completely failing women. And I tell people, I'm like, I'm not in the business of creating frail women. Like you have to eat.

Speaker 3:
[24:20] Protein is priority. I address it with every client. How much are you getting? Are you measuring? Are you calculating? And then we talk about it because they think they're getting enough and they, sorry, one egg is only six grams. I'm sorry.

Speaker 2:
[24:31] I have an egg for lunch. I'm like, great, that's six. I love the egg for that because it's like so simple to count grams of protein with the egg, but it's only six.

Speaker 3:
[24:38] No, we have to look at it. We have to measure it. And I think when we can break things down into smaller meals and spread it out, it's really not that hard to get. And especially if we can take our traditional kind of sweet high carb breakfast and make it a little more savory and add more protein, we can get a great jumpstart on the day. It's just finding these little strategies to make it happen, but it's imperative. And I'm with you. I am not in the business of helping women take up less space in the world and be smaller. I'm helping them be stronger. And in order to be stronger, they need to get enough fuel and we can't under fuel our bodies. And that messaging we've had, that how we look and how appealing we are to somebody else is not how we want to present in the world anymore. It's how well we can be independent and continue to do what we love to do with the people we like to share that with for as long as possible.

Speaker 2:
[25:27] Yeah. The feeling of being strong, which is it's very hard to like communicate this, because it's like, if you know, you know, sort of thing, but like the feeling of being strong feels very good. Like there's a level of confidence that comes with that. And it's not just because like genes look really good on strong people, but like, it's like a confidence in your body almost. And like you had shared with that patient of like, she's like, oh, I got this now. Life's just a little bit easier because you're stronger.

Speaker 3:
[25:55] It's a youthfulness too. I mean, actually, as we were approaching some of the activities, they had an age limit on them. And we were looking to do that and we were at the top of the age limit. But I'm like, I don't care. I'm fine. I'm prepared to do this and better prepared than some of these people 40 years younger than I am.

Speaker 2:
[26:10] Yes. Your driver's license is not an indicator of overall health vitality, wellness or risk. And I see that women get that a lot more than men do, I think. We aren't like, well, you're 65, no testosterone and Viagra for you. Like, we never do that with a man, but with women, we're like, you're too old, you're too young. And it's like, I don't think age is as important as people think it is. And certainly, data doesn't support that.

Speaker 3:
[26:33] Right, exactly.

Speaker 2:
[26:34] Talk about, like, is walking... I love walking, and like, there's something to 8,000 steps a day, and there's longevity benefits for it. I'm not saying don't walk. I think my question is, like, why is walking not the only thing we should do? Is maybe a better way of saying that.

Speaker 3:
[26:50] I'll say that to be clear, too. I love walking. Walking is phenomenal exercise. It's associated with longevity on so many different levels. To me, it's as much a mental health as a physical health thing. Being outside, it helps regulate my sleep patterns. All of it. Walking is wonderful. We're not saying don't walk. Many of my clients have come to me and my doctor said, just keep walking. It's not enough. So when we look at bone health programs, we look at osteoporote programs, it should be comprehensive. There's not one magic exercise like a deadlift. There's not one magic thing just like walking or 12 poses of yoga. It should be a comprehensive program. You addressed this earlier. We want to work on mobility. Our joints are moving through a full range of motion. We want to work dynamic balance. We want to work resistance training, not just three exercises. We want to cover all the major muscle groups, pushing exercises, pulling exercises, pressing exercises, squatting, hinging, carrying. These are functional activities that apply to daily life. So walking is great. I think yoga and Tai Chi and those things are also part of a comprehensive program. It's really more than one thing. So people always want, what's the one best this or the one best that? No, let's leave the whole symphony. Don't just pick one instrument.

Speaker 2:
[28:08] I think of it as like it's an active week. I am an active person. Therefore, I walk, I do yoga, I lift weights, all of the things instead of like, well, I need to get 30 minutes of Zone Two on Tuesdays. People are like, it's a lifestyle. And I just think it is a lifestyle. You have to be like, this body is made for movement. It suffers when we don't move it. And how can we fit that into our week instead of it? It's a chore of like, it's an honor to move.

Speaker 3:
[28:38] Sometimes I think we overcomplicate it. It's just, there's too much information out there. Like you say, well, what's my heart rate? What zone am I in? Did I get, how many minutes was this? How many steps was it? Like we're measuring everything to death instead of just getting out and doing it, right? What feels good to your body? Do that. People are like, well, that's the best aerobic exercise for my bone health. What do you enjoy? I mean, yeah, walking is wonderful, but if you rather go cycling, go cycling.

Speaker 2:
[29:04] I love it. I think that like the worst case scenario is people are like, oh, hand grip strength is associated with longevity, right? So they just like sit in the chair and work on like hand crunches. And I'm like, I don't think that's what the researcher studying that had in mind.

Speaker 3:
[29:18] No, no, that's just really a nice little metric that tells us how much you push, pull and carry all day long. It's just it's a nice way to measure that, that how active are you in general?

Speaker 2:
[29:29] I see a lot of people who are like, well, my shoulder or well, my wrist or I can't lift heavy because this whatever it is, my elbow, my this one joint, right? Give me the talk track for getting them over the hump of like, get in there anyways, see somebody who can work with that. Like, how would you respond to be like, I would love to lift heavy, but like, my shoulder?

Speaker 3:
[29:52] Yeah, I love this question, actually. There's a question comes up all the time. And one of the things I say is, there's always something somebody can do. We don't have to start at the top. So one, if you have a bad shoulder, you got three other limbs and a core. So like, we got other places to work. We don't have to just stop there. A lot of people say, oh, well, I had, I had wrist surgery, so I can't exercise. Yeah, you can, you have two legs, let's go. There's still options that we can do things that aren't eliminated. Maybe they have MS or Parkinson's or different things or other barriers to some of the higher intensity exercise. But nearly everyone can work on balance, okay? Nearly everyone can work on balance and help reduce their fall risk. And nearly everyone can work postural exercises, whether they're lying on their back, they're lying on their stomach or doing and sitting in a chair. Nearly everyone can do postural exercises, which can also reduce fracture risk. And then we go there, we start with, where are you? What can we do? So you have a bad shoulder, we can start to do sit to stands. We can hold weights in a different way. In some cases, maybe a weighted vest would help you do load where you're not having to use your shoulder. Maybe we're only holding it on one side, that still works. We're getting core strength and different dynamic stability. There's always an option, even if one body part isn't working. That's not a reason to not strengthen. And we have evidence that tells us, say that you did hurt your wrist or your elbow on one side, and it's in a cast, if you're exercising the other side, we get some cross communication in the brain that helps that side of the cast. It's a miracle.

Speaker 2:
[31:20] It's so cool. The body's phenomenal. Okay, well, same scenario, except for now it's just kind of chronic pain, low back pain. Maybe they don't have a shoulder injury per se so much, but I can't work out because I have pain. Let's tackle that one.

Speaker 3:
[31:35] Oh, okay, love it. So pain is so multifactorial. So I like to try to really create a safe space for somebody who's experiencing pain. What is their understanding about why they're having pain in their back? Have they been told they have stenosis or bulging discs? Or what is the reasoning? Because a lot of it is, well, what do we think about what's happening? What is our prior experience about that? Has anybody told us that movement isn't safe? And so if we've been told that, that we are fearful of movement. So understanding the root basis of what this pain experiences, what has worked, what hasn't worked. So if something already hasn't worked, that's not going to be where I start with somebody. No, I want to know what has worked for them. What movement feels good? If we know what movement feels good, then we can expand on that. What movement do you enjoy? Okay, I really enjoy swimming. Great, let's see how we break this down into components and parts so we can start to have small successes. Exercise can help pain. Exercise can help reduce pain. So that's part one is finding movement that feels safe, that they trust, that they feel listened, heard and validated in their pain experience. The next is, how is their nutrition potentially contributing to inflammation and pain? What can we do to help guide them in ways that are going to help reduce inflammation, help their joints feel a little bit better, help them have a little bit better fiber? How do we help nutrition to support that as well, or eliminate some things that may be contributing to pain? How is their sleep? Are they getting adequate rest when it comes to managing pain? So I really try to look at pain from a multi-modal approach of what are some of the contributing factors, what are areas we can change, and what is movement that they feel safe doing so that we can start to get a little momentum and build from there.

Speaker 2:
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Speaker 3:
[34:40] Young as kids, you know. One, if we're kids that were active and playing, great. That as our bone is growing. So we're building our peak bone mass from teens into our twenties, right? We're still building that most bone density that we're going to have. Hopefully in that time in our teens and twenties, we're getting enough calcium, enough vitamin D and we're active. We're playing, we're climbing, jumping, running, hopping, doing those things that stimulate bones to grow. We're not on compulsive diets, we're getting adequate fuel for whatever activity we're doing. So we need to be paying attention to this early and we need to help teach our young women how important that is. Some bone stress injuries in endurance athletes that are experiencing low energy availability because they're not getting enough fuel, and they're doing these endurance sports and bone stress injuries can be a big red flag. Maybe they're having changes in their period cycles that are showing some hormone dysregulation. This is a really big sign that they need to work with their provider to sort this out and protect their bone density then. As we're looking into perimenopause, we stay pretty stable until we start to hit perimenopause. That last year of perimenopause, and then those first two years after our last period, we can see a very accelerated amount of bone loss. So addressing that, talking to your provider about hormones before, right? This is your zone, Kelly. Yeah. Well, yeah.

Speaker 2:
[36:03] And I want to remind people that estrogen is FDA approved for the prevention of bone frailty, prevention of osteoporosis. Because a lot of people, for a while it was like, are you suffering enough to justify your hormone use? The millennials are really taking this on to be like, well, how about we don't get low bone density in the first place? How about we don't suffer in the first place? And the shocking fact, like you just said, is bone density, your greatest risk of bone density loss or greatest rate is in the two years leading up to when your periods are going to end. Well, a third of people don't have periods to even know when that is going to be. And how do you know when your period is going to end? That's a date in the future, right? So really thinking of hormones as prevention, protection, preservation, whatever non-trigger word people want to use for that, instead of are you suffering enough to justify this prescription, is really becoming outdated pretty quickly.

Speaker 3:
[36:57] Yeah, absolutely. The earlier the intervention, the better. The more aware we are of our bone health, the better. And on that line, the standard is to get your DEXA at age 65, which is like 15 years past average age of menopause. Right, right. So you can talk to your provider about any potential risk factors. If you had a parent that had osteoporosis and sustainable fractures, that could be enough that you could get one covered. If you had absorption issues, celiac disease, if you had low intake of calcium, protein, if you had an eating disorder, if you had bariatric surgery, if you had to take steroids for long periods of time, these are all things that can help you get that test early. And if not, even just ask, hey, can I get my DEXA sooner than later? You want to know.

Speaker 2:
[37:38] DEXA, depending upon the town you're in, DEXA in my town is like $100 cash. Like this is not expensive technology. This has been around for a very long time. And again, you might have to take it with a grain of salt, know how if you can be with somebody who knows how to interpret, especially if you're a thin-boned, smaller-bodied, and to be like, okay, well, it says osteopenia at age 48, but let's optimize everything. We'll recheck it in a year, and we'll recheck it either with the ultrasound or we'll recheck it with the trabecular bone score included because we care about that microarchitecture. Because I think DEXA does, and we have data on this, this isn't just my opinion, DEXA will over-diagnose osteopenia in thin-boned people. So you want to make sure the test you're getting is accurate representation as it can be.

Speaker 3:
[38:24] And it's one factor of a risk for fractures, one factor of what else is happening. Yeah, one factor. So what are the other factors that we can look at? Well, you're already exercising, you're already have a healthy diet, you're already getting adequate sleep, you're not a smoker, you're not a drinker. What are all the other factors that can play in to your risk for fracture? It's just one.

Speaker 2:
[38:45] Yeah, it's just one. I think there's an interesting data coming out, there's multiple papers on this, looking at women with an estradiol of zero, so undetectable, versus an estradiol of say 20. Meaning, it's still a postmenopausal estradiol level. It's still lower than a man's, right? They use 30 as the cutoff for menopausal estradiol level. Just zero to 20, the risk for fracture skyrockets when it goes down to zero. So where I think this might be going at some point is, should we just get everybody off the floor? Because getting you to still have a postmenopausal estradiol, but still better than zero estradiol, gives you huge gains in fracture prevention.

Speaker 3:
[39:30] Yeah, that's great. I mean, I think that's where we need to keep our focus, is fracture prevention.

Speaker 2:
[39:35] Yeah, absolutely. Anything else we missed? What do you want women to know going into this? I think we tackled fear wonderfully. We tackled multifactorial lifestyle wonderfully. What do you want to leave us with?

Speaker 3:
[39:47] Muscle loss and bone loss are two branches on the same tree. Leaves are falling off one branch, they're falling off the other branch too. And working on your strength to whatever capacity you're capable of is one of the greatest gifts you can give yourself to stay independent and active for the second half of your life. It is one of the greatest gifts to not have the same change that you perhaps saw in a parent or grandparent or aunt and uncle. Movement doesn't have to be perfect. Any movement you do is better than no movement at all.

Speaker 2:
[40:18] I love that. I think there's a lot of black and white thinking in the world, and certainly we apply that to this, too, of like, this is how it is. What's the point now? When I was a child, my great grandma was still alive, and she was very short. And she had the classic Dowager's hump that you learn about in school, which we don't see much of anymore. Correct me if I'm wrong. That's a kyphosis.

Speaker 3:
[40:43] Hyperkyphosis.

Speaker 2:
[40:44] Hyperkyphosis, curvature forward of the upper spine, right? And apparently, it's supposed to be very painful because your bones are basically like riding on each other and they're not in alignment. And I remember that as a kid of that's what great grandma looked like. And I don't see it much anymore. And it's like, we're getting to the point where culturally, we're seeing people age and we're starting to think, what if frailty is not inevitable? And I think you're part of that movement, and I thank you profoundly for your work in the space.

Speaker 3:
[41:16] Thank you.

Speaker 2:
[41:17] All right, everybody, Brickhouse Bones on YouTube and your website. And if you're lucky enough to be on the I-5 corridor in Washington state, you work in Tacoma.

Speaker 3:
[41:28] I do, come on down.

Speaker 2:
[41:30] Awesome, thanks for being with us today.

Speaker 3:
[41:32] It's absolutely my pleasure.

Speaker 2:
[41:34] If you found this episode funny, helpful, insightful, please take a moment to follow, rate and share the You Are Not Broken podcast with someone who might need this conversation too. That support is how this information reaches more people. And thank you. For courses, books, and my monthly membership and the Casperson Clinic information, visit kellycaspersonmd.com. This podcast and all content from Dr. Kelly Casperson is intended for educational and informational purposes only. And this is not a substitute for individual medical, coaching, or psychological advice, diagnosis, or treatment. Always seek the guidance of your qualified health care professional with any questions you may have regarding your health. Never disregard or delay medical advice because of something you've heard on this or other podcasts. Thanks for being here. And remember, you are not broken.