Musicians' Health Collective

Musicians' Health Collective: Supporting the health of musicians (and normal people)

Filtering by Tag: bones

Osteoporosis, and Why Your Bone Density Matters

About 54 million Americans have osteoporosis and low bone mass. It affects one in two women over 50! However, daily exercise and movement can help prevent low bone mass.-2.jpg

I recently went through the statistics for search queries on the blog, and one that came up was "violin and osteoporosis," which I thought was worth addressing.  We typically think of osteoporosis as something that old fragile ladies get, but frankly, it's something worth thinking about for both men and women, especially as we move past the peak bone density period of our twenties.

Simply put, osteoporosis is weakness of the bones, which causes them to be more brittle and susceptible to breakage.  The precursor to osteoporosis is osteopenia, meaning low bone mass.  Our bones are in a constant cycle of regrowth (ossification) and resorption (removal).  These two processes remain in balance throughout our youth, but as we age, there is often more resorption, and less ossification.  This is turn can cause a reduction in bone mass (osteoblast cells are less active than osteoclasts).

When I was at my doctor's office, I took a few pictures of this model spine, which shows a range of spinal issues.  Focus on the bottom three, (green, pink, and yellow), which compares bone density for osteoporosis (green), osteopenia (pink), and normal (yellow) bones.  Notice how large the porous surfaces are with the osteoporosis?

When I was at my doctor's office, I took a few pictures of this model spine, which shows a range of spinal issues.  Focus on the bottom three, (green, pink, and yellow), which compares bone density for osteoporosis (green), osteopenia (pink), and normal (yellow) bones.  Notice how large the porous surfaces are with the osteoporosis?

There are many factors that affect osteoporosis, from genetics, diet, and exercise, to hormonal levels due to cancer treatment, prescription medications, thryoid issues, or other endocrine dysfunction.  Osteoporosis affects one in two women, and one in five men, so this is definitely not a ladies' disease.  I became acquainted with osteopenia a few years ago when I was being treated for my pituitary adenoma (non cancerous pituitary tumor), which completely threw all of my hormones out of whack, essentially putting me into the hormonal cycle of menopause.  Our sex hormones (as well as the hormone thyroxine) stimulate bone cell growth and osteoblast activity.  This means that low estrogen and low testosterone negatively impacts your bone density, regardless of age or gender.  This also means that if you have a thryoid issue (most commonly underactive thryoid or hypothyroidism), and you take medicine to balance your hormones and TsH (thryoid stimulating hormone), you are also at risk because the meds you take may either overbalance or underbalance said hormones.  This is also true if someone has had hormonal treatment for cancer, i.e., hormone replacement therapy for breast cancer, ovarian cancer, etc.  Osteoporosis is a definite secondary risk from many forms of cancer and subsequent treatment.*

*Quick aside: before I was diagnosed with my tumor two years ago, I knew very little about endocrinology.  Now, a few MRI's, many articles, and many blood tests later, I know a bit more.  I highly recommend learning about your own health issues as much as you can, so that you can have dialogues with your doctor about medicines, side effects, long term care, etc.  It's made a HUGE difference in my treatment.*
This image is a bit more difficult to process, but do you see the shape of the vertebrae is actually different?  The top four vertebrae are all compressed, whereas the healthy bone on the bottom is normal shaped and the disc isn't compressed either.  The top two vertebrae are fractures (anterior wedge and compression) and green is osteoporotic and pink is osteopenic.

This image is a bit more difficult to process, but do you see the shape of the vertebrae is actually different?  The top four vertebrae are all compressed, whereas the healthy bone on the bottom is normal shaped and the disc isn't compressed either.  The top two vertebrae are fractures (anterior wedge and compression) and green is osteoporotic and pink is osteopenic.

So why am I discussing this?  Well, musicians (and frankly most people) tend to be sedentary (risk factor for osteoporosis) and our occupation forces us into a sitting situation for 6-8 hours a day.  Our peak bone density occurs in our mid twenties, which means that most of you lovely readers have already peaked!  As we begin to work towards our thirties, forties, fifties, sixties, and seventies, regardless of gender, we need to take care of our bones.  In addition, many musicians don't challenge their upper body strength out of fear of injury which doesn't help muscle or bone strength.  In looking at aging populations, one of the biggest risks is falling and balance, in conjunction with osteoporosis.  Hip, wrist, and spinal fractures are a serious risk which could put a musician out of commission for months to a year.  The good news is that bones also grow in response to mechanical stress, so daily exercise in a gravitational context (not swimming or cycling), walking, and weight bearing activities are really beneficial for your bones.  Osteocytes build bone in response to stress of 72 seconds (according to Dr. Loren Fishman), so for example, if you hold a plank for 72 seconds, you are hypothetically fortifying your upper body bones. If you do standing lunges, squats, and other body weight exercises, you are also fortifying your bones.  Since this is an isolating research study, I would imagine this applies to more dynamic movements such as walking, running, yoga, pilates, weight lifting, and all body weight activities. Biomechanist Katy Bowman writes that osteoporosis is not an all-body disease, but often restricted to specific location which also lacks movement and loading:

  • Ribs(This could serious affect breathing, which is a major issue!)
  • Wrists (If you're a musician, this is particularly scary)
  • Vertebrae (Hello, back issues)
  • Head of the femur (top of the thigh bone)

From a musician point of view, we want to keep our bones healthy and prevent fractures to our axial skeleton (spine, neck, sacrum, etc.)  Healthy bones permit a long lifetime of music-making.

Want more resources?

Katy Bowman has a few great articles on osteoporosis as well as a great podcast on bones.

Buff Bones is a great exercise program developed by Rebekah Rotstein addressing osteoporosis and osteopenia.

Jill Miller writes on Osteoporosis

Yoga For Osteoporosis in the Huffington Post: I don't love the demo pictures in terms of alignment, but the content is solid.

Why Astronauts Get Osteoporosis, by Brooke Thomas (Also interesting to think about in the context of the film Gravity, and why it wouldn't be possible for Sandra Bullock to swim/crawl/etc)

A Quick Dose of Back Side Anatomy

Most folks have a vague idea of what's going on in their backs, but let's clarify.  In your vertebral column, you have 24 vertebrae: 7 cervical (neck), 12 thoracic (thorax-ribs area), and 5 lumbar.  The cervical vertebrae are the most mobile, giving you the ability to turn your neck in many positions.  The thoracic ribs articulate with your 12 sets of ribs to protect the viscera, assist in breathing, etc.  The lumbar vertebrae are larger, less mobile, and support the weight of the torso.

When viewed from the side, the spine has a series of natural lordatic and kyphotic curves.  Poor alignment often distorts these curves into a single C curve.

When viewed from the side, the spine has a series of natural lordatic and kyphotic curves.  Poor alignment often distorts these curves into a single C curve.

In between each vertebra is a cartilaginous "invertebral disc," which I mentioned last week in relation to osteoporosis.  These discs act as shock absorbers while also helping to maintain the structure of the spine.  Misaligned discs can be painful, or not.  Many people have slightly herniated discs (meaning displaced) and have no pain or symptoms from it while others have serious issues, including compressed nerves and persistent pain.

Image from Grey's Anatomy of Erector Spinae and intermediate spinal muscles.

Image from Grey's Anatomy of Erector Spinae and intermediate spinal muscles.

Muscularly speaking, there are many layers of muscle stacked on top of each to make up this portion of your posterior kinetic chain (a fancy way of side your backside).   Our deepest level of posterior muscles are a series of very small muscles running between individual vertebrae, specifically the transversospinalis muscles.  They assist with maintaining healthy curvature of the back, as well as bring the spine into extension, or what we think of as a backbend.  The intermediate musculature is what you see here on the right-this series of long cord-like structures, which assist in extension as well as side bending in the spine. 

Superficial musculature is often more of what you can see on someone's back side-muscles like the trapezius, latissimus dorsi, etc., both of which play a major role in moving the shoulders and neck, as well as spine.  (Lats are a big player in pull ups, and the trapezius often gets very tight and restricted in musicians).

A detailed look at the muscles of the back and shoulders, courtesy of Encyclopedia Brittanica.  The left view is the topical view, sans epidermis, and the view on the right peels one layer of back myofascia off to look deeper. 

A detailed look at the muscles of the back and shoulders, courtesy of Encyclopedia Brittanica.  The left view is the topical view, sans epidermis, and the view on the right peels one layer of back myofascia off to look deeper. 

I found this image on the internet, but I have no idea where it came from.  I do love it, though!

I found this image on the internet, but I have no idea where it came from.  I do love it, though!

Your spine moves ultimately in 6 directions- round, extend (hello cat/cow), side bend both sides, and twist both sides.  The musculature of your back (as well as the muscles of your front) help support the spine and organs as you make these movements, which help keep the invertebral discs healthy, and lengthen compressed areas in the body.  The muscles of your pelvis and abdomen are also incredibly important to postural maintenance and stability, but we'll talk about those another day.

Can you see how if a musician is short in one side of their body, due to an asymmetrical instrument, they might have misalignment and back pain?

Move More, Sit Less

If you read fitness and wellness articles as much as I do, you'll notice there's a new trend, with sensationalist headlines like:

Image and article from the August 2013 issue of Runner's World.  I don't necessarily know if sitting is the new smoking (I think high heels win for that title), but we could definitely do with sitting less often.

Image and article from the August 2013 issue of Runner's World.  I don't necessarily know if sitting is the new smoking (I think high heels win for that title), but we could definitely do with sitting less often.

"Sitting is the New Smoking"

Sitting Is Bad for You. So I Stopped. For a Whole Month.

Are You STILL Sitting?

And of course, Why Sitting Is Killing You

So what's the problem here?  Why all the fuss about sitting?  If you do your 45 minute workout and then sit at work (teaching, orchestra, etc.), then aren't you following healthy movement protocol?  Not so much, actually. 

First of all, sitting all day, standing all day, walking all day... any perpetual action isn't inherently good or bad-It's the quality of movement plus the elapsed time spent in that activity.  If you walk and stand a lot, but wear poor shoes and have dubious movement patterning, then you could easily be in pain.  (Hello waitressing, customer service, retail, nursing, and teaching !)  With sitting, most of us sit on our sacrums instead of our sitz bones (which by now, you have seen discussed frequently, from sitting for children to sitting on a bike...) and then we sit for 8-10 hours a day.  (Drive to work, sit to bike, sit to play, sit to eat, sit to hang out with friends, sit to type, write, etc.)   Try Katy Bowman's How Much Do I Sit Quiz for a good reality check on how much you're actually sitting.

So back to the task at hand.  What are some of the consequences of perpetual sitting?

Sitting looks pretty scary, eh?

Sitting looks pretty scary, eh?

1.  Musculoskeletal problems from poor alignment.  Ahh, repetitive stress injury, I know thee well.  We've mentioned some of these issues already, but here  are a few of these again:

Head Forward yielding Neck Issues

Sitting on the Sacrum and Not the Ischial Tuberosities

Slump in the Upper Body (excessive spinal flexion)

Let's not forget that our muscles and bones respond to the stress we put on them, so the musculature of your hips, back, core, shoulders, etc., will start to lose mobility if you're constantly sitting, especially in poor alignment.  Remember, when you bring these issues to your normal seated position, they follow you when you play in orchestra, chamber music, recitals, driving, etc.  They're a real pain (pun intended).

2.  Cardiovascular Issues.  Katy Bowman's blog is great for explaining this in more detail than I can, but short form summary, even if you lower your cholesterol and you "exercise" every day for an hour, you can't undo the effects of sitting.  Your blood cells pass through your arteries, hopefully smoothly, but sitting creates more of a maze like structure for cells to pass through.  It's like an obstacle course for your blood cells, and if you've already got thickened arteries from genetics and other factors, your body is more at risk for cardiovascular issues.  (She explains this so much better than I do because she is a science-y lady, not a violist.)  This makes sense though-you can be an ultra marathoner on the weekends and still have heart disease, even if you have high intensity workouts planned frequently. 

"You can’t undo 8 hours of wounding with a run or with bigger muscles. Fitness doesn’t touch the wound that has been created." - Katy Bowman

3.  There are various other studies that link computer use and sitting with an all over decrease in movement, which affects weight, lymphatic flow, blood flow, muscle strength, etc, and frankly, science hasn't made an all encompassing statement on all the bad things that happen to you when you sit all the time.  I think we can all agree that we should sit less though.

Ok.  So now what?  If you're a cellist or pianist, you're logging some serious sitting time, i.e., 8-10 hours a day sometimes, if you practice, teach, rehearse, drive, bike, and type.  That's more than most of us sleep, which is distressing.  Rather than try to undo that with intense cardio or weightlifting, let's move more.  Walk more often.  Take breaks and stretch every half hour or so.  Have meetings while walking.  Stand while typing.  Pay attention to how you sit in the car.  Make phone calls while walking rather than while sitting. 

More on that next time, but start noticing how much you sit every day.  Seriously. 






Bones of the Arm and Forearm

Most musicians have a vague idea of where their arm bones are, but let's get a bit more specific here.  

photo 2 copy.jpg

If you were a child of the 80's and 90's and you remember amazing slang like "tubular" and "radical" and Wayne's World, this reference will make sense.  Otherwise, work with me.

Ulna.jpg

Now before we get more complicated, is everyone clear?  The upper arm bone is the humerus, which I previous covered in shoulder posts.

download-1.jpg

Here's a more detailed and accurate image for this, from Paul Roache, an orthopedic specialist in northern California.  Why is this relevant?  In order to talk about the muscles of the wrist and arm, as well as tendon and nerve issues, it's good to be clear about the basics first.  

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