Menopause, Frozen Shoulder and the Joint Pain Wake Up Call with Dr. Jocelyn Wittstein - Part 1

21:52Dr. Mary Claire Haver:There's 50 different ones on the market, and they're all different. So this gets into my whole thought process about I just feel like we need less siloed approach to studying musculoskeletal conditions that have this intersection with women's health. Because people really want to answer this question, but they're using insurance databases that pull, oh, these people were on oral contraceptives. It's more nuanced than that. Yeah, there's so much nuance in my field that people outside my field are not going to know. And there's so much nuance in women's health that I don't know. And I'm an orthopedic surgeon with a very high interest level in women's health.

22:23But I consult all the time with my partner, Ann Ford, who is in women's health at Duke. I constantly ask her questions to help me clarify things because, and I pull her into studies all the time because I need her expertise in the study to do it right.

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26:06Dr. Mary Claire Haver:I broke my foot when I was pregnant. 25 weeks, tripped on a curb. you know, had a fifth metatarsal fracture. They brought in a pregnant woman, you know, into the ER with a broken foot. And like the entire orthopedic team came in and like, I was a space, like, you know, I was an alien. They didn't know what, they were so scared to hurt the baby. I'm like, you can put a cast on me. Like you can do what you need to do. You know, I just realized I'd never met any of these people. I rarely saw them, that we had just, there was no interaction between our two specialties. Yeah. Other than when the one pregnant resident comes in with a broken foot.

26:40I mean, I want to get back to orthopedic conditions with sex disparities. But I will tell you, the gateway to my connection to women's health and all this work that I do came from the fact that my mom's favorite doctor over the course of her entire life, my mom's gone now, but was Ann Ford. And so for like 20 years, she'd be like, I just love Ann Ford. Ann Ford is the best doctor. This is her women's health doctor. She was like, she's like, she, oh my gosh, she just, my mom raved about her. So one day I'm in the break room and thank goodness my office is directly on the same floor across the hall from Duke Women's Health.

27:12And I'm in the break room and I see this woman with a badge on and it says Ann Ford. And I said, you're Ann Ford? I have heard about you for at least 15 years. And, you know, we started talking and ever since that moment we have worked together. That's awesome. But because she meant so much to my mom.

27:30Dr. Mary Claire Haver:Yeah. No, that's a great story. I often wondered how the whole frozen shoulder story. We'll get to that. We'll dig into that later. But let's talk about, let's go back. So we talked about ACL. Right. So then I think the next most obvious condition, I mean, there are little ones you see here and they're like dequerivane, tenosynovitis, which happens to like new moms, but also like perimenopausal women. So much. So much. Plantar fasciitis you see more of. But the one that's really, really obvious to me is frozen shoulder, like we've talked about. So it's just a condition that mostly strikes women.

28:06And really the only men who get frozen shoulder are men with diabetes and usually poorly controlled diabetes. So, you know, another inflammatory state. So frozen shoulder is a condition that for many decades was described as idiopathic, which is a fancy word for we don't know what causes this. I hate the word idiopathic. Because you're an idiot. Yeah, but, you know, something cannot be idiopathic that almost entirely affects women, but not men. And almost entirely affects women between the age of 40 and 60. That's the typical time frame. But what frozen shoulder is, and it's also called atisic capsulitis, if you see that term.

28:40But it's typically a non-traumatic or sometimes minimally traumatic situation where you didn't have a big injury, but your shoulder becomes very painful and then subsequently very stiff. It's a process where the lining of the shoulder joint, you may hear the serum capsule or synovium. Think of just sort of the lining around the whole ball and socket joint of your shoulder becomes inflamed and thick and fibrotic. and our phases. One of my friends, Johanna Fan, who is in the forum with me, the Women's First Medicine Group, has described this very well over the years, including, you know, looking at the actual, you know, pathophysiology in the capsular tissue.

29:22But there is an inflammatory phase where the shoulder becomes very, very painful, you know, like pain at N-range emotion, just like, okay, with the mid-range, we get the N-range and ow, like super painful, leads to guarding. Then a frozen phase where it becomes not so painful, but just really stiff with women can have extreme lack of motion. I mean, I've had women come in who cannot rotate their arm out to the side or lift it up at all. And I just don't know how they can.

29:47Dr. Mary Claire Haver:So they can't brush their hair. They can't put their bra on. They can't put their arms behind their girlfriends in a picture. Oh, yeah. Common things are I can't shave under my opposite armpit, cannot tuck in a shirt or fasten a bra. Yeah. Washing your hair, you know, things like that. All very common. And then there's a thawing phase, which could take one to two years. And if a woman has diabetes, that is the worst case scenario. Women with diabetes can have a really prolonged course of frozen shoulder. But, you know, I really believe this is hormonally related. This happens mostly to women between the age of 40 and 60.

30:21There are a lot of estrogen receptors in the synovium or, again, lining of the shoulder joint. And estrogen has been shown to inhibit cells called fibroblasts in the lining of the shoulder joint. So these cells that can like thicken and stiffen the capsule. I think you're aware we presented a study on this at NAMS or now the Menopause Society.

30:43Dr. Mary Claire Haver:So I want everybody to understand women have been having this condition forever. And she and her team, you know, the co-authors were the first people to even suggest that this may have something to do with menopause since it usually happens in women between the ages of 40 and 60. Yeah. And it didn't go over well at first. Right. Like, yeah, I mean, what made you think of this? What made you wait a minute? So I work in a network where I can, it's a closed network, not a closed network, but the primary care doctors, all the notes, everything are in there. I can see what's going on with my patients.

31:20And I can see that they're seeing their doctor for sleep disruption, night sweats, hot flashes, lipids creeping up, things like that, anxiety, you know, all these other symptoms associated with perimenopause and menopause. And I just started, I also started asking my patients. So, you know, the first clue was like, I have all these women with breast cancer who have this. And I started thinking, well, I mostly see this in women. And then, you know, it's in this age group. And estrogen is an anti-inflammatory hormone. I just sort of started just putting these pieces together and then these other, you know, complaints that they're having all kind of together.

31:57And I just, I think the thing that first set me down the path was the effect of aromatase inhibitors. And I ended up talking to Anne about this and I said, this has to be a symptom of menopause. So this was like actually during COVID. I spent hours and hours and hours, days and days and days manually doing chart reviews of like thousands of charts.

32:20Dr. Mary Claire Haver:I just, yeah, this is the important part. I want our listeners to understand is that the work that goes into getting the scientific proof. Yeah. That this could be correlated because the whole world is going to tell you no. Yeah. you know, as being the first person to make this correlation. As you know, use of menopausal hormone therapy is less than 5 % in women in the United States. Now, in our population, because I work with women's health doctors who are ahead of the curve, I would say on top of things, not to say other people are on top of things, just they're, I think, have a higher percentage.

32:53I think it's about 8 or 9%.

32:55Dr. Mary Claire Haver:Typically in academics, we see that. Right. But even so, if you only have 8 or 9 % of people on hormone therapy and the rest are are not, and you have several thousand women that you're looking at, it's hard to get the numbers you need statistically. So we need to do more research on this. And what we ended up finding in our study was that women who used menopausal hormonotherapy that included estradiol, systemic, not just local, had half the risk of developing frozen shoulder as compared to those who didn't. However, we approached statistical significance, didn't reach it. And then the other thing is, when you look at our confidence intervals, they didn't overlap.

33:34So, you know, if we could have just had more patients, some more patients, I think we would get there. And I mean, just the number of cases of frozen shoulder in the hormone therapy group were so small. But again, you know, we need larger numbers. So I did a post hoc power analysis, you know, and I know how many we need, but I can't go back and get more because this was, it had to be, I used patients that were in an an enclosed system, meaning they're within our HMO. So there's not leakage. I'm not missing data. But I have ongoing perspective work that I do with our women's health group. We enroll people in something called our musculoskeletal symptoms of menopause registry.

34:14We survey them every few months, you know, follow them with timing of onset of hormone therapy or not. So we're doing that prospectively. And I have a very large cross-sectional study that we'll be coming out with that I actually collaborated with Vonda right on in terms of distributing. And that was great that she was able to collaborate with us. And we have huge numbers and we'll be coming out with that. And I don't want to say what it shows yet, but it does confirm our suspicions. I have that in submission. And so I think it's becoming more and more obvious and people are recognizing this more and more.

34:46Dr. Mary Claire Haver:When that paper was presented at the Menopause Society, I talked about it on social media. And it was one of the most viral videos that I've ever had. I remember that. And so many people reached out to me. They're like, are you the doctor she's talking about? Because you're like doctors at Duke University. And I was like, I think I am. But I do want to say there are I think about this all the time in women's health. If you look hard at older data, there are pieces here or there. Right. There are clues. There are clues that just haven't been brought together because they're, you know, siloed. There are clues.

35:20There are clues as to why, you know, women have more arthritis than men. A lot more. And they're here and there. Some of it's in the orthopedic literature, you know, some of it's in women's health literature. But when you if they're not all brought together, they just don't work as well.

35:33Dr. Mary Claire Haver:Have you published in orthopedic journals any of this data? No, not the frozen shoulder data I've tried. I've also tried. I wrote a piece on managing, you know, hormone therapy and oral contraceptives perioperatively. And I sent it to so many orthopedic journals, even got preapproval to write editorials on this. you know yes this is approved submit it submit it to JAMA surgery all these places and then they would get it and review it and be like oh this isn't you know no just kidding we're not going to publish this or I don't know if this is of interest to our readers and you know and it's like 51 percent of the population so I eventually published it in a journal women's health is niche yeah on earth so that paper for instance I eventually published in um a journal uh that Miho Tanaka, who's at Harvard, is the lead editor of, which is Journal of Women's Sports Medicine, to give people guidance about how you manage exogenous estradiol perioperatively in orthopedic surgery.

36:36You know, oral estradiol has some increased risk, transdermal, much less, little to none, vaginal, zero. You know, you don't have to hold that around the time of surgery. But it's just interesting, like sometimes these things that are so significant and affect so many people are just, it's just hard to get it to where I want to, you know, get it. Oh, regards to frozen shoulder. This is very interesting. In some cultures that are highly prone to frozen shoulder. Such as? Asian cultures.

37:02Dr. Mary Claire Haver:Okay. Like there are certain Asian cultures that have their own term for frozen shoulder, which translates to 50 years older. Like that is also not a coincidence. like their term is 50 year shoulder and some women just full on expect to get 50 year shoulder oh yeah my mom got 50 year shoulder all right so again if you listen to people and it's just this is not random so i i wanted to share that anecdote because no that's that's actually meaningful to me like if you just listen to terminology within various cultural groups they're telling us this is something that happens to women when they're 50 yeah especially since we're talking about frozen shoulder, I am a gynecologist, have zero training in orthopedics, but because it's such a popular theme on social media and, you know, I'm always asked, how do we avoid it?

37:50Dr. Mary Claire Haver:What can I do if I develop it? You know, is there prevention? And then how do we take care of it? What do you do? Yeah. So one of the most important keys to treating frozen shoulder is if you think you're developing it, so you didn't have a traumatic event really, or something very mild, then you have this new onset severe shoulder pain and you start to notice you're losing range of motion, even just a little bit. Like if you look down and you try to like rotate your arms out to the side and you see even just like a 10 degree difference, like that's not normal. Like normally you're gonna have normal range of motion.

38:20Yeah, I tell people this all the time, especially when they're in treatment for frozen shoulder, like just check yourself, make sure you're not losing it after we gain it. But go see someone early. This is not, ideally, I think an orthopedic surgeon or you could see like a primary care sports medicine doctor, someone who will give you a glenohumeral joint injection, an injection into the ball and socket joint. You're basically trying to combat or reverse as soon as possible the inflammation of the lining of the joint. And frozen shoulder is the best indication for use of a steroid injection, I think, in all of orthopedics because it is not a Band-Aid.

38:54It's like a cure. Is it ever too late? So if you're three or four months into the process and you've already started to lose motion, there is less efficacy of the injection. I'll still give it to people because they're still in pain. It just doesn't work as well. If I catch someone within three months of onset of the symptoms and I give them an injection, it'll often restore their emotion, make the pain go away. And half of those people, I never see them again.

39:18Dr. Mary Claire Haver:Okay. And they hug me when they come back, if they come back, because they're so happy. What percentage will get the contralateral, the opposite shoulder? I don't know an accurate statistic on that. I would say anecdotally in my own patient population, you know, maybe like 20 percent. OK. But so some people need a second injection. The idea is you keep the inflammation at bay. You're shortening the course of the inflammatory phase, trying to get them to not freeze up so much or shorten the course of the frozen phase that they can then thaw. What about physical therapy? You will read in textbooks and are like examinations.

39:52The correct answer is send people physical therapy. But physical therapists and I will tell you, if I send you to physical therapy in the throes of the inflammatory phase, it is not going to help. So if you're in that very painful phase and I send you to physical therapy or your primary care doctor, whoever send you to physical therapy, oftentimes the physical therapist is going to recognize you have frozen shoulder and be like, I can't help you right now and send you for an injection. Because if you have pain and range of motion and someone is trying to help you move it and let you move it and at the end of each end range, you're like, ow, ow, ow.

40:21By the end of the session, it's inflamed and you guard more. It's kind of exacerbating. Okay. So if you're in physical therapy for frozen shoulder, but it's making you worse, not better, it's not that your therapist is doing something wrong. It's just that's the nature of the condition. It's not the right phase, I think. You don't get as much out of physical therapy. So doing the injection early is helpful. Once we get you out of the painful phase, and I will bring people back usually six weeks later and check them, if I can rotate them and at the end of the arc of motion, they're not painful, they're just still a little limited, then we do physical therapy and it's more helpful then.

40:54And then rarely people need surgery for this. I mean, I don't operate on many of these because it is a self-limited course and people do get better. And most people don't need, like we call license of adhesions or manipulation, but some people do. You know, I think certainly less than 10 % of people. So I think using physical therapy at the right time or phase is important so we don't exacerbate things. And then the other thing I always do, whenever I have a woman with a frozen shoulder, I always take basically a perimenopausal or menopausal history. I always ask them, are you having hot flushes?

41:23Are you having night sweats? You know, like what else is going on with you? And I make a lot of referrals to women's health, probably three to five per day in my orthopedic clinic to women's health because they're having these concomitant symptoms. and do I have proof that initiating, you know, systemic estradiol reverses or makes your shoulder better or makes you not get on the other side? No, but I'm studying that. But does it make sense to me that it would? It does make sense to me that it would. And they need their other symptoms treated anyway.

41:59Dr. Mary Claire Haver:And that your data so far suggests that HRT could be preventative. Is that a correct statement? Yeah, our evolving data. I don't want to like, I got to get it out there in the right way. But yes, that's what I'm seeing. I want to do this the right way and get it accepted and reviewed and everything. But yeah, that is my feeling. Okay. Springtime is almost here. And if you've been itching to redo every room in your home, Bob's Discount Furniture can help. When you shop at Bob's, you get well-worthy everyday low prices on fabulous furniture for every room. Everything from stylish mid-century dining sets and top-rated Bob-O-Pedic mattresses with the best warranties in the business to pop-up sleeper sectionals all for a fraction of what they cost elsewhere.

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43:45Dr. Mary Claire Haver:So frozen shoulder is part of the musculoskeletal syndrome of menopause, which is a new term. Is everyone like arms open wide accepting this term? Is the terminology receiving pushback in certain organizations? I mean, I think people question, is menopause arthritis just, do you just have arthritis because you're aging? There are a lot of things that we can attribute to just aging. Progression of arthritis, loss of bone density. But some of these things accelerate in a different way at age 50-ish in women versus men. And what we see is the premature, what really stands out to us is some of these conditions in the people with premature ovarian failure.

44:30Dr. Mary Claire Haver:Yes. You see this rapid. Rapid. You know, in their metabolic health. Or surgical menopause. Yeah, or surgical menopause. Right. Which is, again, like takes me back to the aromatase inhibitor revelation. Or the AI of patients, yeah. You know, it's like, yes, these people have the most exaggerated version. Surgical menopause is the human equivalent of the studies on the oophorectomized rat. I'm in no way comparing my lovely female patients to rats. No, but we don't have a perimenopause model. It's the parallel. In animals. There's no perimenopause model. They either take out the ovaries and they're surgically menopausal.

45:07Dr. Mary Claire Haver:And then they do the experiments. Or we don't have, there's no transition states in the rodents. Yeah, there's not a mouse perimenopause model. Yeah, model. They're trying, but it's so complicated. We are so complicated. Yeah. You know, musculoskeletal effects of menopause are multiple and some are more silent than others. So, you know, more accelerated loss of bone density, increased joint inflammation and risk of arthritis. Women over 50 are 35 percent more likely to have arthritis than men. And that difference doesn't equilibrate until age 80. So that is a disparate aging of joints. And so that's just not normal aging.

45:50Well, I guess it is normal aging for women because women do normally go through menopause. But I'm saying it is probably a modifiable thing, right? Right. As is osteoporosis.

45:58Dr. Mary Claire Haver:We know that. And we're Agent T's FDA approved for the prevention of osteoporosis. And then getting back to the mouse versus human situation, you know, we talk about muscle mass and maintenance of muscle mass. as we age, both men and women do lose muscle mass. Now, there are some studies that show that men and women don't have different rates of muscle mass loss over 50. There was a recent systematic review that looked at hormone therapy that included estradiol and showed, like in this meta-analysis, that it didn't actually make a difference in terms of helping women maintain muscle mass. On the other hand, some of these studies use like older forms and older ways of assessing for sarcopenia.

46:37Right. And then there are some new studies coming out that I read one recently out of Thailand where there was a positive effect of hormone therapy with estradiol on muscle mass. There's a very interesting Finnish study where they have followed these sets of monopsychotic twins like for years and years and years. And it's a small study, but they had these 15 twins sets where one woman was on hormone therapy and one wasn't. Oh my gosh. And they've followed them for years and they show that they're, again, this is a small study, but so niche. And how would you get this group? Because they have such good studies in Scandinavian countries.

47:14And they show a positive effect of hormone therapy on maintenance of muscle mass. So I think that is evolving. And I think in terms of the whole muscle mass aspect of thing, like I would like to see more research on, and it's possible I just haven't found it because I'd read a lot of research, but I also have a full clinical and surgical schedule. So I could easily, I could miss something, but I don't think.

47:38Dr. Mary Claire Haver:Don't be shocked. We have so many listeners. Someone is going to do a deep dive for you and you're going to get an email. I would love this. I haven't seen. Are some researchers going to be listening to this and being like, I have the data. If someone is doing research and has data on more like muscular endurance or fatigue with or without hormone therapy, I don't know the data on that. And I wonder about that. And I think about that because we think about it in sports medicine sometimes in terms of, you know, and that's one of the hypotheses about maybe potentially having increased ACL risk during luteal phase is there more muscular fatigue at a, you know, lower estrogen state.

48:16And we know that estrogen relates to, you know, glucose utilization and metabolism in muscle. So it would make sense to me that there could be some effect on, you know, fatigue. But in any case, so we have potential effects on muscle. Some of that thought process comes from what we know about mice, o-fractorized mice having less satellite muscle cells, loss of muscle mass. Now, like you said, we don't really have a perimenopause or menopause model necessarily with mice. It's more like an equivalent of surgical menopause. And there is some data that suggests that women with surgical menopause maybe are more at risk for sarcopenia as compared to just regular menopause.

48:51Dr. Mary Claire Haver:And we've talked about it previously on the podcast, but sarcopenia for new listeners is the loss of muscle mass to the point where you lose function. So if you want to explain what sarcopenia is. Yeah, obviously a more extreme version is you're having so much weakness that you're frail. You're frail. I mean, like grip strength less than 17 kilograms or something like that for women. But in general, obviously everything is on a continuum from a large amount of muscle mass to less and weakness. But there's some data suggest that surgical menopause would put people more at risk for having some loss of muscle mass than...

49:24Dr. Mary Claire Haver:Good someone who had natural menopause. Yeah, or more at risk for like completing a survey that indicates your strength and muscle function being more at risk for sarcopenia than natural menopause. So I think we need more information about there are basic science things that make sense in mice models. I think maybe we'll learn more going forward about actual, you know, what actually happens to muscle mass with some of the more, you know, modern day utilizations. But those are kind of the components. So you've said that musculoskeletal health might be the most overlooked dimension of women's health.

49:59Dr. Mary Claire Haver:Why do you say that? For multiple reasons. So the most, one of the largest impacts lifelong of estrogen withdrawal is osteoporosis, which largely affects women and is a silent condition. So it's easy to overlook it until so late in life that you have a hip fracture or, you know, a vertebral compression fracture. And then who are you seeing at that point? Usually a male surgeon. Yeah. And at that point, you know, yes, you know, for instance, where I work, we have a fracture, a fragility clinic that we send people to after a hip fracture, vertebral fracture. And we, you know, many of these people haven't been tested for the bone density or haven't ever had like a zelendronate infusion or something like that.

50:44And we're getting them down that path, but it's so late. And so I think there's this weird thing that happens where women are obviously receiving a lot of lifelong health care through their women's health providers. There's a silent disease, which, you know, prevention of osteoporosis is and has been for a long time an FDA-approved indication of menopausal hormone therapy for protecting your bone density. But the end result of declining estrogen levels and more bone resorption than bone building is this progression to osteoporosis, then fracture. The end result is so far down the line that the people seeing at the end of the line were not there at the beginning of the process.

51:20And so, again, it's this siloed approach. And I'm on our, you know, fracture fragility committee, and I'm pushing really hard to get our distal radius fractures, you know, your wrist bone fractures, which peak for the first time in women between the age of 50 and 60. I want that group to go to the fragility clinic. The silver lining of if you fall and break your wrist, I mean, there's good and bad things to this. If you're a 50 something old woman and you fall, same level fall and break your wrist, depending on the study you read, you have a nearly 50 percent or maybe 200 percent greater risk of eventually breaking your hip as compared to a woman who never had a distal radius fracture.

51:57But this group of people, if you had a distal radius fracture, you are the group I want to focus on, because if I get you to a fragility fracture clinic and I get you had DEXA before the age of 65 and you're diagnosed with osteopenia and you make your hormone therapy decision about potentially bone health as the driving factor may be, and you're in the window where you can safely start. You're in the window of opportunity because, again, these are happening in women in their 50s. This would inform you and you may say, okay, I don't want to have a hip fracture. I am at increased risk for a hip fracture.

52:30Maybe you have osteopenia, not osteoporosis. And we know that hormone therapy that includes estradiol will increase your bone density over time and protect you against fractures, you know, quite significantly. So I think we need to shift our thought process towards, obviously, earlier prevention. But in my world... We get a...

52:50Dr. Mary Claire Haver:We ask. We try to get a bone density on everybody. Yeah. In my world, I think we need to focus, like, capture these wrist fractures because at least we're not so far down the line. So bone health is silent. Some of the other things are less silent. What else can a woman do to prevent osteoporosis? So many lifestyle things. That's how I found you. Yeah, yeah. Yeah. Many lifestyle choices will help you protect your bone density. And so many people, as you know, are not candidates for hormone therapy. So hormone therapy alone will not be really enough probably, or certainly isn't the only way to protect your bones.

53:25So lots of data. And, you know, you've talked about a lot of times about strength training and everyone hears the saying you have to lift heavy. And I do want to say because I'm an orthopedic surgeon and I see people, not everyone can lift heavy and that's OK. But there is evidence that heavier strength training, higher intensity does increase your bone density more than moderate and lower intensity. But there's still benefit to moderate and lower intensity. Yeah, they both they both will can help you increase bone density. And of course, the classic trial that everyone knows, which is an amazing trial, the Liftmore trial, you know, a great trial that used women who were menopausal with some of them osteopenic, some of them osteoporotic, and they did back squats, deadlifts, overhead presses, and jumping chin-ups, and they kind of ramped them up to high intensity over eight months, and they gained 3 % in their lumbar spine and also significant gains in their hips.

54:16Strength training is very effective. But for people who cannot do that high intensity, you know 85 % single rep max type lifting like don't give up and just be like I can't do that there's definitely benefit to moderate and low intensity so I just want to say that yeah jumping or impact you know is also a great way to improve your hip bone density the most of the like load bearing strength training exercises will have a larger effect on your lumbar spine than the hip so that's your back yeah your back there is still some benefit with strength training to your to your hip region to your hips. But there is a specific effect with jumping and impact this mechanical load or this process called mechanotransduction, which basically creates like a biochemical reaction in your bones and stimulates bone formation, is more effective in perimenopausal women than menopausal women, but there's still benefit for menopausal women.

55:05So one study showed over a six-month period that included jumping a few days a week, maybe 30 jumps each time, that there was about a 1 % improvement in hip bone density in menopausal women. But if you look at similar studies of perimenopausal women, you may see gains of, you know, 2 % in the hip region with these interventions that could be one study compared 10 versus 20 jumps a day, another did 50 jumps a day. And then that study in perimenopausal women actually showed an increase of like 3 % in the hip region. So impact is very effective. And we know that from studies of children, participating in exercise with impact.

55:41They accumulate more bone mass. So impact is great. Now, there are people who cannot do impact because, again, I'm a orthopedic surgeon. I have so many patients like, that's great. I would love to do that. And I get tons of messages from people. That's ridiculous. I can't do that. And I'm like, I'm sorry. I'm just trying to share information about what jumping can do. But there are lots of modifications. And so if you have terrible knee arthritis and every time you jump, your knee swells. That is not going to be a good option for you. You can do heel drops. You can do jumping on a rebounder, which doesn't do as much as land-based jumping.

56:10You can do jumping in a pool. Again, not as much as land-based jumping, but better than sedentary. And so impact, that's a broad category. What about vibratory plates? Yes, so those have mixed results. If you look at meta-analyses of these, you're certainly gonna see like half of studies that had no effect, half of them had some effect. The most effective, I would say like formulation, if you're trying to think about using a vibratory plate, uses a 30 Hertz speed. So that's high speed vibration or frequency, I should say. Low magnitude. So you don't want the big magnitude of vibration. You want to be the studies show 0.3 G.

56:48So that's called low magnitude, not like 1 G, which is like a larger vibration, actually. Interestingly, there's something about vibration that seems to be beneficial of this like low magnitude. And then the exposure time matter. So the downside of using vibration plates is the studies that show benefit. but you're basically having to do this 20 minutes every day.

57:08Dr. Mary Claire Haver:Okay. And that's probably most people aren't going to do that. Yeah. But I do tell people who are, you know, there's so many people like, I can't do this, I can't do that. I have all these limitations. And that's probably a reasonable thing for you to add if you can do that, you know, 20 minutes a day. And then other components people need to include, because it's not all about just bone density for fracture prevention, balance, some agility work. So when we talk about fracture prevention, we talk about limiting your chance of falling. Right. You want to reduce falls. So balance is key here. So what do you do for balance?

57:37I was a gymnast. I literally love standing on one leg. I mean, it is the most natural. I love standing in tree pose. Sometimes I just stand on one leg. If I'm waiting for an instrument, I just stand on one leg. Me too. But it's just it's so I do it without thinking. It's so comfortable to me. And I think but I have patients. I'm even teenagers. I ask them to stand on one leg and they're wobbling. That's not good. So, you know, single leg balance is a really easy thing to practice. You can brush your teeth standing on one leg and switch, you know, when you switch, I don't know, your top and bottom teeth or whatever.

58:15That's easy to do. But, yeah, I think tree pose is a very easy thing to recommend. And you can try to do other things while you're standing on one leg. But it's such an easy thing to do. If you're waiting in a line, you can stand on one leg. You can practice, you know, like bending over and picking something up, standing on one leg. It's like a little mini single leg deadlift, things like that. If you have balance issues or inner ear issues or, you know, you fall frequently, like maybe like keep yourself near a wall or something. But yeah, I think it's important to just practice balancing. And agility work is just sort of anything that makes you move your feet kind of quickly.

58:50That's another thing when I recommend it to people. Like, I can't do that. And you can do less intense forms of jewelry. It's just a matter of helping yourself respond to your external environment so you're less likely to fall. What about the weighted vest?

59:01Dr. Mary Claire Haver:There's a lot of weighted vest, misinformation, hate. I have one and I love mine. Yeah. So the funny thing is, like, rucksacks have been around for years. Exactly. The military uses them to train their members, their athletes. So the data on weighted vest is it's it's the problem with it is that some of the studies are very small and then some of the follow up studies are on even a smaller portion of the original study. And they're usually using mixed methods. So they're not only wearing the weighted vest. The subjects are also doing some strength training and some other things. So we can't attribute necessarily improvements in bone density to just using a weighted vest.

59:41But there are some studies that indicate there are improved parameters of balance and strength and things like that. And I like it for cardiovascular exercise. It adds to my walk. If I walk my dog, I put on that or a rucksack. If I wear a rucksack, I feel like I get a little bit more maybe core work. But so it's they're certainly not harming people.

1:00:00Dr. Mary Claire Haver:I like it for balance training. Yes. And there's so many things that I like to tell people are the opposite of disuse. And now we think about data on things that stimulate bone density and jumping. You know, we want to create a big impact, something that's going to create a force more than three times your body weight to stimulate bone formation. situation. But if you think about the opposite extreme of things, like if you're an astronaut and you're in microgravity and you're not putting any weight on your bones, just the absence of standing or having like your body weight on your legs will make you lose one percent of your bone density per month.

1:00:30So in contrast to that, what if I were on crutches? If you're on crutches for like six weeks, you get diminished bone density in your whole leg and loss of muscle mass. And it may take one or two years for your bone density to return to normal, like in all parts of your femur, For example, from just not walking. So then what about walking? Does walking, you know, put a load three times your body weight with every step? No, but it is the opposite of disuse. And it does slow bone loss over time. And people who walk regularly have less risk of fracture. And the end point isn't always bone density.

1:01:02Dr. Mary Claire Haver:It's not fracturing. Not fracturing. Yeah, which is different than your bone density. And so I really like to tell people use is the opposite of disuse. It's not like everything you have to do has to, like, make new bone and it's worthless. Like, if you're not—these other activities are beneficial, too. And so, you know, you're adding a little bit to your walk. So I don't think Weighted Vest are, like, the magic cure-all, but I think they're a nice addition or tool. And they get people excited about going out and walking and getting a little extra workout in. I always feel a little breathier if I'm out walking.

1:01:34Dr. Mary Claire Haver:My followers tell me it's like the perimenopausal, like, badge of honor. You know, like you're like when you see someone walking with their weight of vest. So I think there's nothing wrong with it. I don't want to like exaggerate what they'll do for you, but I think they're a nice addition. Now, if you have terrible knee arthritis, the funny thing is, like, they're not for everyone. Yeah, I tell people, you know, because we know if you lose like 10 pounds, your knee is going to feel a lot better. You're taking some load off your knee. So I have patients have terrible knee arthritis. I'm like, that might not be for you, especially downhill walking with weight of vest.

1:02:02You might make your knee hurt some more. But if your joints are tolerating it, I think it's fine. It's fine.

1:02:08Dr. Mary Claire Haver:As a reminder to our audience, you can follow Dr. Whitstein on Instagram at jocelyn underscore Whitstein underscore MD. Her book, The Complete Bone and Joint Health Plan is available on Amazon. I'd love to hear from you about this topic and anything else that's on your mind. You can find me on Instagram at Dr. Mary Claire and get honest and accurate information on health, fitness, and navigating midlife at thepawselife.com. My upcoming book, The New Perimenopause is available for pre-order on Amazon. If you're loving this podcast, be sure to click follow on your favorite podcast app so you never miss an episode.

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