Updated: Feb 21, 2021
Recently in clinic I've asked a few patients to consult with their GP's regarding blood tests or bone density scans to rule out osteoporosis/osteopenia, so I thought I'd write a blog post on the condition to raise awareness.
Osteoporosis is a condition which describes low bone mass/density, with a consequent increase in bone fragility and susceptibility to fracture. Osteopenia is the name for the earlier stages of this.
It is thought that around 3.5 million people in the UK have osteoporosis and by the age of 80 there is a 50% prevalence of osteoporosis in women. The tricky thing is that this condition may not be clinically apparent until people sustain a fracture as many people are symptomless until this point (and crazily enough even 2/3 of vertebral fractures may be painless!).
The most commonly associated fractures are of the hip, vertebra (spine) and wrist.
The life time risk of fragility fracture is as high as 40% for white women and although, as stated above, some people may not have many symptoms, for others fractures can have a large detrimental effect on their lives.
A survey performed by the National Osteoporosis Foundation revealed that 86% of women with osteoporosis had never had preventative measures discussed with their physicians. Therefore, going forward it's clear that awareness and prevention of osteoporosis is something to work on.
So, first, a bit about...
The science behind bone remodeling:
Bone is continually remodeled (resorbed and then formed again) throughout our lives due to microtrauma from day to day movement.
There are different types of bone: denser outer cortical bone and more spongey inner cancellous/trabecular bone. These both contain a matrix mainly made up of calcium (mineral), which provides compressional strength, and collagen, which provides tensile strength. In adults, approximately 25% of trabecular bone and 3% of cortical bone is resorbed and replaced each year.
There are two key mediators in bone remodeling: Osteoblasts and osteoclasts.
Osteoblasts make bone (by laying down and mineralizing osteoid). Osteoclasts break down the bone.
In osteoporosis, the coupling mechanism between osteoclasts and osteoblasts is thought to be unable to keep up with the constant microtrauma to the trabecular bone. Osteoclasts take weeks to resorb bone, whereas osteoblasts need months to produce and mineralize new bone. Therefore, any process that increases the rate of bone remodeling results in net bone loss over time.
(Osteomalacia/Rickets is more a disorder of decreased bone mineralization due to vitamin D deficiency, leading to soft bone, whereas in osteoporosis the mineral to collagen ratios are normal and bone is brittle).
Risk Factors for Osteoporosis:
Gender- being female
Age- over 65yoa for females, over 70yoa for males. Women lose 30-40% of their cortical bone and 50% of their trabecular bone over their lifetime. Men lose 15-20% of their cortical bone and 25-30% of trabecular bone. Bone mass peaks around the third decade of life and slowly decreases afterward.
Genetics- family history
Alcohol- 3 or more units daily
Diet- low calcium intake, current/previous eating disorders. Low Vitamin D, often due to lack of sunlight.
Gastrointestinal disorders which may decrease calcium absorption e.g. Crohn's/Ulcerative Colitis/Coeliacs/Chronic Pancreatitis.
Steroid medication e.g. Prednisolone (over 7.5mg for over 3 months). Steroids increase osteoclast activity, decrease calcium absorption from the gut and decrease muscle mass.
Other medication e.g. Proton Pump Inhibitors (often used for reflux), Selective serotonin reuptake inhibitors (often used for depression), Oestrogen inhibitors (often used in those with breast cancer), Antiepileptic medication (such as Carbamezipine), Pioglitazone (sometimes used in type 2 diabetes).
BMI- Low Body Mass Index (under 19)
Hormone levels- low oestrogen e.g. post menopause/early age of menopause. Low testosterone e.g. due to anti-androgen prostate cancer treatment.
Thyroid issues e.g. Hyperthyroidism/hyperparathyroidism.
Kidney or liver failure.
Autoimmune/inflammatory conditions such as rheumatoid arthritis, ankylosing spondylitis.
Other chronic conditions e.g. Diabetes Mellitus, Multiple myeloma, MS, COPD.
The risk of fracture from osteoporosis also links to our risk of falls. This can depend on: neuromuscular weakness/incoordination, visual impairments, cognitive impairments and the use of alcohol and sedative drugs.
Calculate your risk... Questionnaire's:
Q fracture tool... QFracture-2016
FRAX tool... https://www.sheffield.ac.uk/FRAX/tool.aspx?country=1
(These are a good rough guide, although it's noted that the FRAX may underestimate certain risk factors. Scenario: Assessment | Management | Osteoporosis - prevention of fragility fractures | CKS | NICE)
Signs and symptoms to look out for...
As I mentioned above, osteopenia, osteoporosis and even sometimes spinal fractures may not always present with symptoms at all. But some things to look out for, especially if you have some of the above risk factors, may include:
Generalized back ache, usually in the mid back, potentially sudden sharper pains with bending/lifting. Often alongside local muscle tightness and tenderness.
Increased thoracic (mid back) kyphosis (rounding), which may lead to a what's called a Dowager's hump and a loss in height. (Height loss of more than 4cm may be due to osteoporosis related vertebral fractures).
DXA scans (dual-energy x-ray absorptiometry) are the gold standard to assess Bone Mineral Density (BMD). The reading at the hip is most helpful. BMD is usually measured using a Z score (which is a comparison against others your age) and a T score (which is a comparison against a healthy thirty year old's bone density).
In T score readings: over -1= normal, -1 to -2.5= osteopenia, below -2.5= osteoporosis, below -2.5 and a fracture= severe osteoporosis.
These may be repeated within 2 year periods, depending on the individuals risk factors.
Blood tests for Vitamin D and Calcium.
Other blood tests may also be needed to work out the route cause of the osteoporosis e.g. liver/renal function, thyroid function, testosterone and hormone levels, full blood count to look for anemia secondary to other conditions.
Lifestyle changes are very important...
Weight bearing exercise e.g. walking outside. Ideally alongside a mix of strengthening exercises, balance and flexibility exercises (to help prevent falls). Thai Chi, Yoga and Pilates are great in these respects!
Decreasing smoking and alcohol intake.
Improving diet, especially calcium intake, to at least 700mg/day (this is the equivalent to a pint of milk. A small pot of yoghurt of matchbox size amount of cheese is around 200mg). Use this calculator to work out roughly what your intake is... CGEM Calcium Calculator (ed.ac.uk).
Improving vitamin D levels.
Prevention is key. It is best to maximize bone density early in life, especially as females, to optimize the minerals in our 'bone banks' as such!
Medication & Supplements...
Vitamin D and Calcium.
Bisphosphonates- e.g. Alendronate (Guidelines need to be followed on how to take this medication Bisphosphonates | Prescribing information | Osteoporosis - prevention of fragility fractures | CKS | NICE)
Other medication may be used if Bisphosphonates are contraindicated such as: Denosumab, Teriparatide, Strontium ranelate or Raloxifene.
HRT- especially considered in women who have gone through an early menopause (pre 40 years old).
Hands on treatment- as chiropractors, osteopaths and physios we see a lot of patients with underlying osteoporosis. Treatment can consist of gentle hands on approaches such as spinal and other joint mobilisation techniques, soft tissue work like massage and dry needling/acupuncture and, as mentioned above, a gradual home exercise program.
So, in conclusion... be aware of your risk factors for osteoporosis and where possible prevent the likelihood of developing the condition with the more controllable factors such as regular exercise, lots of vitamin D and a healthy, balanced diet!