Basics of osteoporosis

Osteoporosis (Greek: bone with too many passages) is a condition in which the holes in the bones become larger. Instead of bone, the spaces are filled with fat or bone marrow cells and the bone density is decreased. The bones are weak and break easily.

Immediate medical attention

Osteoporosis does not cause symptoms unless the bones break. Usually the broken bones are painful, especially fractures of the wrist, ankle or hip.  These serious fractures happen after a fall or injury.

Facts and myths

The most common misconception is that osteoporosis is a disease of old women. Osteoporosis is frequently seen in men and it can occur at any age.

Another myth is that hip fractures cause falls.  In 95% of cases, the hip breaks after a person falls.  There might be rare exceptions.

Prognosis

This chronic condition is one of the leading causes of disability in aging men and women. Hip fractures can cause loss of independence.  Vertebral fractures (also called "compression fractures" in the spine) cause discomfort and may interfere with breathing.

Lethality

Osteoporosis is not usually listed as the cause of death on a death certificate. But it contributes to other medical problems. The one-year mortality following a hip fracture is 12 to 24%.   It is estimated that 14% of deaths following a hip or pelvic fracture in previously ambulatory women were caused or hastened by the fracture.Many people die in the year after a hip fracture, from problems such as bleeding, infection, and blood clots.

Pain

The most typcial fractures are of the spine, wrist and hip. Osteoporosis is not painful until the bone actually breaks. Fractures in hips and wrists are always painful, but about 2/3 of the spine fractures do not cause pain. The spine (vertebral) fractures cause height loss, curvature of the spine, disfiguring posture, and muscle aching. When women and men do suffer painful compression fractures, the pain usually lasts from one to two months, is localized to the back with accompanying muscle spasms, then gradually subsides. In severe cases the ribs can rub on the pelvic bones which is painful.

Debilitation

The "Dowager's hump" caused by vertebral compression fractures is disfiguring. This is the feature of osteoporosis that is identified by most patients. The hump causes difficulty in finding clothes that will fit, let alone look attractive.

The protruding abdomen which is a result of the kyphosis is an unrecognized aspect of osteoporosis. Women do not realize that the curvature of the spine decreases the abdominal space, and thus the intestines have nowhere to go except forwards. Many women think that they are getting fat, and they go on a diet trying to regain their youthful waistline. If they do successfully lose weight, it will only increase their risk for more osteoporotic fractures.

Patients with kyphosis may develop reflux esophagitis due to the changes in abdominal space. Wearing tight clothing can exacerbate the problem.

Curability

Osteoporosis has many causes, and sometimes the disease can be cured. The most common form, however, is due to aging.  Although there are medicines and life-style changes that can help the osteoporosis of aging, it is not possible to grow younger and really cure the disease.

Fertility and pregnancy

It is unusual for a woman to have osteoporosis when she is young enough to have children. When this does happen, the osteoporosis is often a complication of another disease, and the ability to get pregnant would depend on that other disease.

Osteoporosis itself does not prevent a woman from becoming pregnant, but in severe cases women get fractures in their spine during pregnancy.  These are painful but do not harm the baby.  

If a woman has serious osteoporosis, her physicians might try to deliver the baby by Cesarian section because her pelvic bones might not be able to allow safe passage of the baby's head.

Independence

Osteoporosis is one of the leading causes of loss of independence. After a hip fracture many patients need nursing home care.

Mobility

After a hip fracture, some patients will not be able to walk. Other patients will eventually walk again, but they will need rehabilitation and physical therapy.  This will depend on how healthy a person was before the hip fracture, how severe the fracture was, and what kind of surgical treatment was done.  It is important to work hard and follow exercise programs after a hip fracture.

Women and men who walk regularly during middle-life can strengthen their muscles, improve their balance, and reduce their chance of gettting a hip fracture when they become older.  One-half to one hour daily is recommended.

Daily activities

The irreversible height loss associated with osteoporosis is one of the aspects of the disease that is most distressing to many women. They have trouble reaching high shelves, driving the car, and are at greater risk for airbag injuries.

Energy

Osteoporosis does not cause changes in metabolism. But changes in metabolism can cause osteoporosis.  The most important cause of osteoporosis is decrease in estrogen, one of the sex hormones that is made in the ovaries.  During menopause the ovaries don't make normal amounts of estrogen, and this causes the bones to dissolve.  Another hormone is called "parathyroid hormone", made by glands in the neck that are next to the thyroid gland.  This hormone controls the calcium in the blood and in the bones.  Sometimes the glands make too much hormone and this results in osteoporosis.  The hormone made in the adrenal glands, called cortisone, also can cause osteoporosis.

Diet

The Surgeon General released a report about osteoporosis in 2004, and recommended that all people should eat adequate amounts of calcium. The calcium can come from the food (especially dairy products, tofu, some grean vegetables and bones of fish), fortified foods such as orange juice or cereal, or from supplements.  Adults need 1200mg of calcium each day to help promote strong bones.

Vitamin D is also important.  This is not found in very many foods, but is added to dairy products in the USA.  Most people will also need to take vitamin pills to get an adequate amount of vitamin D.  The current "official" recommendation is 400 units a day but many doctors think that older men and women should get at least 800 units a day. 

Thin persons are much more likely to get osteoporosis.  In fact, obesity is good for the bones (although it has other health problems).  The "body mass index" is a way of telling if a person is too thin for his or her height.  If the body mass index is lower than 20, eating extra calories to gain weight would be beneficial.  The upper limit of normal body mass index is 25.  The body mass index can be calculated using the on-line calculator from the National Institutes of Health.

Incidence

In the USA, about 45% of postmenopausal women have low bone density. The lifetime risk of a fracture of the hip, spine or forearm is 40% in white women and 13% in white men. African-Americans have fewer fractures than people of other races. Worldwide the rates of osteoporosis are variable, but in every country age is one of the most important risk factors. As more people live longer lives, the number of those with osteoporosis will also increase.

Acquisition

Osteoporosis has many causes. Most people who get fractures from osteoporosis have more than one reason, and some people have five or six reasons.  These are called risk factors.  The most important risk factors are age, Caucasian or Asian race, female gender, parent with a hip fracture, chronic medical disease, use of certain medications (including prednisone, seizure drugs), cigarette smoking, thin weight, decreased estrogen levels, poor muscle strength or balance, and poor nutrition.

Genetics

Heredity plays an important role in osteoporosis. It is estimated that 80% of the strength of the skeleton is inherited from a person's mother and father.  The other 20% depends on "life-style", such as diet, exercise, smoking, alcohol, and medical diseases.

There is not a single gene which causes osteoporosis.  Instead, there are several genes, and when they act together they can cause the disease.

Communicability

Osteoporosis is not contagious. Certain infections, however, can act like osteoporosis and cause fractures.  World-wide, the most common infection to cause fractures is tuberculosis, which can result in fractures of the spine that can look just like osteoporotic fractures.

Lifestyle risk factors

Lifestyle risk factors are important contributing causes of osteoporosis. To achieve the best bone strength, people should:

1. Exercise, exercise, exercise!  Walking is especially good because it is safe for all ages. 
2. Eat the recommended amount of calcium.The recommended amount of calcium from a combination of diet and supplements is 1200mg/day.
3. Maintain a healthy level of vitamin D through dairy products, vitamin D pills, or sunshine exposure. The recommended amount of vitamin D in older adults is 800 to 1000 units a day; higher doses have not been shown to help.
4. Avoid cigarette smoking.
5. Don't diet excessively, or try to be "fashionably" thin.
6. Don't drink more than 2 alcoholic beverages a day.

Injury & trauma risk factors

Osteoporosis does not result from injury, but when a person with osteoporosis suffers from a fall, or other minor injury, then the bones will break. When there is a major injury, such as a car accident, persons with osteoporosis are more likely to get serious fractures.

Anatomy

Osteoporosis affects all of the bones. The most common fractures related to osteoporosis are in the wrist, spine, and hip.

Initial symptoms

Most of the time there are no warning signs for osteoporosis. Some people will have "compression fractures" of the back, which are not painful but which cause height loss.  A person who loses more than 2 inches in height should ask their physician about osteoporosis.  The height loss can also be caused by scoliosis or disc disease.

Symptoms

The symptoms of osteoporosis are height loss and bone fractures that occur with minimal trauma.

Secondary effects

Patients with "kyphosis", which is the curvature of the back seen after several fractures of the vertebra, can develop heartburn. They also may have trouble taking a deep breath.

Conditions with similar symptoms

• Trauma
• Pathologic fracture from neoplasm
• Osteomalacia
• Paget's disease
• Infections (such as tuberculosis)
• Fibrous dysplasia
• Peripheral neuropathy

"March" fractures from repetitive stress

Diagnosis

A person who has bone fractures with only minor trauma, such as a simple fall,  probably has osteoporosis.  Physicians must determine that other diseases did not cause the fracture. (see above)

Osteoporosis can also be diagnosed with a bone density test.  This is a kind of X-ray that measures the density in the spine, hip or wrist.  Other tests can measure the heel with ultrasound.

A committee of the World Health Organization has defined osteoporosis based on the bone density. Using standardized bone density measurements of the total hip, "normal" bone is greater than 833 mg/cm2. "Osteopenia" is between 833 and 648mg/cm2. Osteoporosis is lower than 648mg/cm2, and "Severe (established) osteoporosis" is when there has been a fragility fracture.

There have been many debates about when bone density tests should be done.  The recommendations also vary from country to country.   Many doctors in the USA suggest that the bone density should be done for women older than 65, men older than 70, and persons with serious risk factors.

Diagnostic tests

Bone density tests can estimate the risk of a fracture, but can not tell if an individual person will or will not break a bone.

Other blood and urine tests, X-rays, and bone scans can help a physician decide if other diseases caused osteoporosis or caused a fracture.

Effects

The bone density test is easy, can be done in about 15 minutes, and is painless.

Health care team

Osteoporosis is a common disease. The diagnosis is made by a physician or a nurse practitioner.  There is no medical specialty devoted to osteoporosis.  Physicians who diagnose and treat osteoporosis can be in the following specialties: family practice, internal medicine, endocrinology, rheumatology, radiology, orthopedics, nephrology or rehabilitation medicine.

Finding a doctor

Because there is no specialty for osteoporosis, it is not easy to know which physicians in any community have the most knowledge and experience with osteoporosis - especially in complicated cases. A patient should ask his or her primary care providor about recommendations for a referal if a specialist is needed.

Treatment

The first step in treating osteoporosis is to start all the lifestyle factors discussed previously.

If a patient has already had a fracture, then prescription medication will be beneficial.  If there has not been a fracture, but just low bone density, then sometimes prescription medications will help to reduce the risk of getting a fracture.  Many of the medicines used to treat osteoporosis are new (available within the last 5 to 10 years) and so the long-term effects are still unknown.  That means doctors are not as sure about long-term prevention as they are about treating a person who already has had a fracture.

In addition to medications, some patients need physical therapy or nutritional therapy.

The recommended amount of calcium from a combination of diet and supplements is 1200mg/day. 

The recommended amount of vitamin D in older adults is 800 to 1000 units a day; higher doses have not been shown to help.

Surveys of hospital discharge records show that osteoporosis treatment is still ignored in many cases.  More education of doctors, nurses and patients is still necessary!

Health care team

Osteoporosis is treated by a team of health care providers including physicians, nurses, and physical therapists.

Pain and fatigue

The pain from osteoporosis is treated with the same medications as other kinds of pain. These medications may include acetaminophen, nonsteroidal anti-inflammatory drugs such as ibuprofen, and narcotic pain relievers.  

Some studies have shown that calcitonin can help to relieve the pain from an osteoporotic fracture. 

Usually the pain is gone once the fracture has healed.  There may be some aching the persists, that is treated with physical therapy and mild pain medicines.

Diet

The diet has been discussed in the prevention section.

Exercise and therapy

Physical therapy can help to increase the muscle and bone strength. For patients with spinal osteoporosis, back extension exercises are recommended.  These can be taught by the therapist, who can help a patient establish a home program for back care.

Sit-ups and other back flexion exercises can increase the risk of osteoporotic fractures and they should be avoided.  Lifting heavy objects also should be avoided.  Lifting and twisting can be particularly stressful to the bones in the back.

Golfing is an activity that puts a twisting force on the spine and can cause fractures.  Contact sports and fast downhill skiing cause fractures even in young healthy people with strong bones, so common sense dictates that it is unwise to engage in these kinds of activities when people have osteoporosis.

On the other hand, many patients with a fracture or diagnosis of osteoporosis become fearful and limit their activity.  This is a bad idea because the bones respond to exercise by becoming stronger.  For the elderly patient with osteoporosis, a moderate approach to exercise is the best, with back extension exercises and walking, stair climbing, and arm curls with light weights.

Medications

The medications used to treat osteoporosis depend on the cause of the osteoporosis. If there is no specific cause, then the following treatments have been approved by the US FDA:

1. estrogen
2. bisphosphonates (alendronate, risedronate, ibandronate)
3. calcitonin
4. raloxifene
5. teriparatide
6. denosumab

Some patients do not want to take any medications and would prefer to just follow dietary and exercise recommendations.  But for those who already have fractures, the benefits of preventing future fractures outweigh the risks and costs of taking the medications.

Surgery

The role of surgery after a spine fracture is uncertain. It is possible to insert a needle into the vertebral body of the spine, and squirt some liquid material that will harden into the spine.   A small balloon can be inserted first, and expanded to make a space for the filling material.  This procedure can restore the shape of the vertebra which had been crushed.  Many patients fell pain relief after the surgery, perhaps because the nerve fibers have been numbed by the filling material. 

The long-term effects of this surgery are not known.  Some studies show that there is not much difference a year later between those who had surgery and those treated with medicine.  There are some risks of the material spilling out into the space around the spinal cord; this can cause paralysis or nerve damage.  There is also a risk of getting more fractures in the bones above and below the surgical site.

At present, research is being done to answer the questions about risk and long-term effects.

Splints or braces

In serious cases of kyphosis (forward curvature of the spine caused by vertbral fractures from osteoporosis) braces can stabilize the spine and provide protection. Physicians in rehabilitation can prescribe these special braces.

Alternative remedies

Hip pads can prevent fractures in frail persons with osteoporosis. Of course, these pads will not work if patients do not wear them.  Some studies suggest that nearly half of the hip fractures could be prevented if all the patients wore these protectors.  They must be the kind designed for osteoporosis.

Various kinds of exercise that improve muscle strength and balance also can help prevent fractures and even  make the bones stronger.  Tai Chi, for example, has been shown to be benficial in preventing hip fractures.

Herbal medications have not been shown to help with osteoporosis.  There is interest in phytoestrogens and soy products.  In high enough doses, these plant products can act like estrogen on the bone.  But studies are needed to show if they also have the side effects of estrogen on other parts of the body.

Many claims are made for "food" supplements, but they have not been tested with scientific trials.  These include boron, coral calcium, progesterone cream and strontium citrate.

Long-term management

Osteoporosis is a chronic condition and frequently treatment involves prescription medications. Physicians follow patients regularly, and may repeat bone density tests or blood tests.  It is important to realize the limitations of bone density repeat testing, because the error of the machine measurement for an individual person is about 5%.  Sometimes patients become worried if the bone density does not increase or goes down slightly, but this might just be an error of the measurement.

Unproven remedies

Some patients think that if some calcium is good for the bones, then more calcium must be better. They drink milk, eat chese or yogurt, and take supplements so their total intake is more than 2,000 mg/day.  This does not help the bones, but it increases the risk of getting kidney stones.

Strategies for coping

Kyphosis is disfiguring, and one stategy for coping is to wear fashions that will minimize the curvature of the back.  Loose, flowing clothing is more attractive. Fashions should not emphasize the waistline. Long, lean lines disguise osteoporosis problems best; fluid fabrics like wool, silk, crepe and rayon flow around problems without clinging to them.

Work

Some patients with serious osteoporosis will have restrictions placed on lifting, especially picking objects up from the floor. Limits of 20 to 30 pounds are common.

Resources

For more information about osteoporosis, read the web page by Dr. Susan Ott from the University of Washington, at http://courses.washington.edu/bonephys .

Condition research

The disease osteoporosis was ignored by medical researchers for many years. As recently as 1980 there were only a dozen grants from the National Institutes of Health about this condition.  Currently, however, the situation has turned around and now there are hundreds of studies.  New treatments are being discovered, new genes are being identified, new methods of prevention are being tested.

Pharmaceutical research

Currently pharmaceutical companies are conducting clinical trials with medicines that have looked promising in preliminary studies. Many of these drugs don't even have a name yet.

Non-surgical research

There are also trials for a unique form of exercise which involves small, frequent vibrations. Preliminary results are encouraging.  Some of the vibrating machines, however, can cause damage to the bone, so these treatments should not be used until studies are more definite.

Surgical research

Studies of the effects of surgical treatment for osteoporosis involve testing the safety of vertebroplasty and kyphoplasty.

Cellular, genetics, or tissue research

New genes for osteoporosis are discovered every year. This is an area of interest to many scientists.  The stem cells in the bone marrow (which make the blood) interact with the cells of the bone, and scientists are working to understand these relationships.

Summary of osteoporosis

1. Osteoporosis is a common problem that can respond to treatment and prevention.
2. Exercise, healthy diet, and adequate calcium and vitamin D are important steps that everybody can take to improve their bone strength. 
3. Osteoporosis affects men, too.
4. Preventing new fractures is the basic goal of osteoporosis treatment.  The bone density findings provide valuable clues but the real reason for treatment is to prevent fractures.
5. Estrogen deficiency is the most common cause of osteoporosis.