Osteoporosis

Musculoskeletal

Osteoporosis (“porous bones”) is a condition of the bones characterized by a decrease in bone density, the lower the density, the higher the risk of fracture. Less dense bones are weaker and can break even with minimal trauma. The weakness and fractures can also affect the shape of the bone causing individuals to have a hunched posture. There are different types of osteoporosis, but the most common variety affects women typically after menopause. The condition is silent and causes no or minimal symptoms until a fracture occurs. For this reason, it is recommended that women get a DEXA scan (determines bone density) after menopause. Estrogen levels drop significantly after menopause and this is thought to affect bone metabolism and mineralization, which causes osteoporosis. Prevention of osteoporosis involves addressing any risk factors if they are present. Certain lifestyle choices increase the risk of developing the condition, especially low physical activity, smoking, and drinking alcohol. With early diagnosis, you can prevent excessive bone loss and improve your quality of life with lifestyle changes and medical treatment.

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Symptoms

Typically, you will not have any signs or symptoms in the early stages of osteoporosis. When your bones lose density, they do not appear any different than normal. But the loss of calcium and other important minerals causes your bones to have less strength and fracture easily. When you have lost enough bone density to weaken your bones, signs, and symptoms of osteoporosis include:

  • Receding gums due to bone loss in the jaw
  • Stooped posture (compression fracture)
  • Loss of height
  • Back or neck pain (caused by fractured or collapsed vertebrae)
  • Fracture from a fall

If you are experiencing intense pain in your back or neck, see your doctor immediately to make sure you do not have a compression fracture.

Types

There are two types of osteoporosis, primary and secondary. Primary osteoporosis is divided into two types, type I and type II. Secondary osteoporosis is also known as “high-turnover osteoporosis”. These types will be explained in more detail in the causes section of this article.

Risk Factors

Osteoporosis is not a universal condition in people. Several risk factors increase your chance of developing it. Certain chronic diseases can increase your risk for osteoporosis (i.e., diabetes, hyperparathyroidism, hyperthyroidism, multiple sclerosis, kidney failure, liver disease, and rheumatoid arthritis). Medications can also increase your risk for osteoporosis. These include seizure medication, immunosuppressive drugs, steroids (i.e., prednisone), heparin, lithium, and thyroid replacement medication. Osteoporosis is prominent in post-menopausal women, but men can also develop this bone condition especially as they age. Risk factors for people include:

For women

  • Early menopause (before age 45)
  • Estrogen deficiency
  • Medications that lower estrogen levels
  • Extended time without a menstrual period
  • Surgical removal of ovaries (before age (45)
  • Smoking tobacco
  • Poor general health
  • European or European-American ethnicity
  • History of fractures (adult)
  • Low calcium intake
  • Alcoholism
  • Low physical activity
  • Falling
  • Poor vision with correction (i.e., wearing glasses)

For men

  • Low levels of testosterone (undiagnosed)
  • Low calcium intake
  • Low body weight
  • Smoking tobacco
  • Alcoholism
  • Family history of osteoporosis
  • Low physical activity
  • Falling
  • Age (bone loss increases with age)

Diagnosis

Your physician will begin the diagnosis with a thorough physical examination. In this exam, your height, weight, and arm span (which gives an estimate of your original height as a young adult) may be measured. Your neck and spine may be palpated for tenderness to assess if you have any compression in the spinal column. After your physical exam, your physician will ask you to get laboratory tests, including a bone density scan. The laboratory tests ordered will reveal if a secondary disorder is causing the bone loss (i.e., bone marrow malignancy, anemia, malabsorption). If your bone density scan reveals that you have bone density loss, your doctor will look at the numbers to figure out if you have osteopenia or osteoporosis.

Osteopeniaoccurs when you have enough loss of bone density to cause you to have weakened bones,but you are not prone to fracture. If you are diagnosed with osteopenia, you have time to prevent further bone loss by developing a treatment strategy with your physician. The bone density scan may also reveal that you have enough bone density loss to place you in the category of osteoporosis. While this may seem overwhelming, know you and your physician will develop a treatment plan that will set your bones on the right track to health!

Imaging tests you may need are:

DEXA (dual-energy x-ray absorptiometry).To diagnose osteoporosis, your physician will order a bone density scan using a DEXA machine. This machine uses x-ray technology to measure the bone mineral density at your hip and lumbar spine. This information is converted into a score known as the T-score. The T-score measures the number obtained by the DEXA exam against a normal population of younger people to assess your risk for fracture and need for drug therapy. A T-score of -1 or less is considered normal. T-score between -1 and -2 will place you in a category of osteopenia. Osteoporosis is diagnosed with a T-score of -2.5 or above.

Bone x-ray. Used in the case that your physician is concerned you have a fracture. Bones that may be x-rayed are your hands, wrists, ankle, feet, shoulders, hip, pelvis, or spine.

CT (computerized tomography) scan. Your physician may order a CT scan of your spine and hip to identify fractures and/or assess alignment issues. This scan can also measure bone density and predict your susceptibility to fractures.

MRI (magnetic resonance imaging).An MRI of the spine also evaluates vertebral fractures. In this case, an MRI can determine if the fracture is new or old and looks for evidence of an underlying disease, like cancer.

Treatments

Before you start medications to treat osteoporosis, your doctor will check your vitamin D, calcium, creatinine, and TSH (thyroid-stimulating hormone) levels. Once a fracture occurs certain medications can be used to help prevent more breaks from occurring. Your doctor will help you develop a lifestyle plan to help you prevent any further bone loss.

Common medications used to treat osteoporosis are:

Bisphosphonates. Inhibit the breakdown of bone while slowing down bone removal. This medication helps to increase bone density and reduce the risk of fractures in the hip and spine. A side effect of bisphosphonates is gastrointestinal upset.

Calcitonin. Prescribed to postmenopausal women who are not taking estrogen. This medication increases spine bone density and slows down bone loss.

Hormone replacement therapy (HRT).Used in prevention and treatment of osteoporosis. HRT with estrogen can reduce bone loss, increase bone density in the spine and hip, and risk for fracture.

Selective estrogen receptor modulators (SERMs). Similar to estrogen, this medication helps to prevent bone loss and has been approved by the FDA as a preventative for osteoporosis.

Alternative Treatments and Home Remedies

Dietary interventions. Make healthy food choices to ensure you are getting enough nutrients to keep your bones strong. Food sources of calcium other than dairy are dark leafy green vegetables, almonds, and whole grains. Magnesium is an important mineral that assists in building bone and absorbing calcium. Dietary sources of magnesium are nuts, whole grains, fish, legumes, and dark green vegetables.

Strontium. This naturally occurring mineral has been shown in studies to treat and prevent osteoporosis, including reducing your risk for fractures and increasing bone mineral density.

Soy isoflavones. These phytoestrogens, or plant chemicals that have the same effect as estrogen, may help protect against osteoporosis. Tofu, soy milk, and soybeans are all sources of isoflavones. Talk with your doctor before you supplement with this phytoestrogen, especially if you have a history of hormone-related cancer. Soy contains a chemical known as phytic acid which may block the absorption of calcium and other minerals.

Omega-3 fatty acids. Found in fish oil. Essential fatty acids may increase the amount of calcium absorbed, improve bone strength, and enhance bone growth. Cold-water fish, like salmon, that have high amounts of omega-3 fatty acids. If you take any blood-thinning medication, talk with your doctor before you take fish oil.

Herbal supplements. Talk with your doctor before taking any herbal supplement. Horsetail, kelp, and oat straw are all herbs that are rich in minerals that support bone health.

Prevention

Screening. Early detection of osteoporosis followed by immediate treatment significantly reduces the number of fractures suffered by people who have bone density loss.

Fall prevention. People over the age of 65 may be more prone to falls which increases your risk for fracture. Looking at your environment to identify hazards in your homes that may cause you to fall will help prevent an accidental fall from occurring. If you need glasses, be sure to visit your optometrist regularly so you have an appropriate corrective vision prescription. Exercise regularly to keep your strength and balance at an optimum level.

Calcium. The best time to prevent bone loss caused by inadequate calcium intake is early in life. At age 30, bone mass begins to decrease. Consider supplementing with calcium after age 30 if you feel that you are not getting enough calcium in your diet alone. Recommended daily allowance for women between the ages of 25-50 is 1000 milligrams (mg) a day. If you are over the age of 50 and do not take hormone replacement therapy (HRT) the recommended daily intake is 1500 mg a day (1000 mg for women on HRT). Men between the ages of 25-65 are advised to take 1500 mg per day. Calcium citrate is better absorbed by the body than calcium carbonate. If you take calcium carbonate, be sure it is with food.

Exercise. Get regular exercise. 30 minutes of healthy physical activity five times a week helps reduce bone loss and builds a strong heart. Weight-bearing exercises are the ideal type of exercise for you to participate in. Weight-bearing exercise is any physical activity that makes you work against gravity to stay upright. Dancing, hiking, and climbing stairs are all good ways to build your bones and keep them strong. If you need a low-impact form of weight-bearing, try using an elliptical training machine or fast walking on a treadmill. Better yet, take a brisk walk with a friend outside for fresh air and social interaction.

Vitamin D. Vitamin D is an important precursor for calcium uptake. Be sure you have enough vitamin D, at least 800 mg per day. Foods that contain vitamin D are egg yolks, fish (i.e., halibut, mackerel, salmon, sardines), shrimp, and cod liver oil.

Lifestyle Changes

Smoking, excessive alcohol consumption, and lack of exercise all contribute to excessive bone density loss, especially with age. Bone mineral density can improve with lifestyle modifications, especially if you have been diagnosed with mild to moderate bone density loss, or osteopenia. The following are changes you can make in your lifestyle to moderate symptoms of osteoporosis:

Normal body mass index (BMI). People with a low body mass index (less than 20) have a higher risk for developing osteoporosis. If you feel that you are struggling with weight gain or an eating disorder, talk with your primary healthcare provider. There are resources available to you that will guide you on a path of healthy eating and nutrition.

Physical activity. A sedentary lifestyle is a primary risk factor for osteoporosis. If you spend much of your time sitting in front of a computer or television screen and choose to not exercise, your muscles and bones will suffer. Studies have shown that active people have a higher bone mass density than non-active people. Therapeutic exercises for osteoporosis are weight-bearing aerobic exercises and strength and/or resistance exercises. Exercise also decreases your risk for falls as the muscles that hold the body up are strengthened and your balance is improved. Brisk walking and climbing stairs combined with balance-building exercises like the practice of tai-chi are excellent choices in your physical approach to bone care.

Quit smoking. Smokers do not absorb dietary or supplemental calcium, as well as non-smokers, do. Heavy smokers have an increase in bone remodeling markers or an imbalance between bone loss and bone-building mechanisms. If you struggle with quitting smoking, talk to your physician. There are helpful strategies that can help you quit, like nicotine replacement therapy and classes centered on smoking cessation.

References

Albany Medical College. (2003).Osteoporosis: A patient’s guide to osteoporosis. Retrieved from:https://www.amc.edu/patient/services/neurosciences/spine_surgery/osteoporosis.pdf

Benedetti, M. G., et. al.(2018, December 23). The effectiveness of physical exercise on bone density in osteoporotic patients. Retrieved from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6323511/

Ferdous, H. S., et al.(2015, January). Osteoporosis: A review. Birdem Medical Journal, 5(1). Retrieved from:https://www.banglajol.info/index.php/BIRDEM/article/view/28371

Healthline Editorial Team. (2019, August 13). Osteoporosis symptoms. Retrieved from:https://www.healthline.com/health/osteoporosis-symptoms

National Osteoporosis Foundation. (2021). Osteoporosis exercise for strong bones. Retrieved from:https://www.nof.org/patients/treatment/exercisesafe-movement/osteoporosis-exercise-for-strong-bones/

Reidenberg, M. M. (2010, June 29). Benefits of screening for osteoporosis. Retrieved from:http://pre.weill.cornell.edu/cert/patients/osteoporosis_screening.html

St. Luke’s Hospital. (2015, March 24). Complementary and alternative medicine: osteoporosis. Retrieved from:https://www.stlukes-stl.com/health-content/medicine/33/000120.htm

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