Osteoporosis – Preventing the Silent Killers “Fractures”

Written by Michele O’Brien, CEO, The Irish Osteoporosis Society

The disease Osteoporosis is commonly considered to affect just “Old” women, and many people do not appear to be aware that this disease is preventable and treatable in most people. Women over 65 are the highest risk group for fractures, however it affects all age groups, including our young. Only 19% of people with Osteoporosis are diagnosed, which is why everyone should be checking to see if they have any of the 200 causes of bone loss.

An example of this is the DXA scan below (figure 1). It shows the results of a 21 year old female who was diagnosed with severe bone loss at 19 in her spine.

Her DXA results show she now has marked Osteopenia in L1 and L3, Osteoporosis at L2 and severe bone loss at L4.

Thankfully she was diagnosed, investigated and put on a treatment plan. You can see from the graph named “AP spine: L2-L4 (L3) (BMD) % change vs Previous”, that in two years she has significantly improved her bone health.

The fact that two of her vertebrae had been eliminated from her DXA scan results, shows that even the young can develop Osteoarthritis, which is why L1 and L3 vertebrae were eliminated. Osteoarthritis can give false higher readings falsely showing the bones are healthier than they are.

This person’s causes of bone loss was due to overexercising, which caused irregular periods and she also had high cortisol levels due to a stressful job. By early intervention occurring the person so far has been able to improve her bone health and prevent vertebral fractures from occurring. Research shows that most fractures occur in the moderate to marked Osteopenia range, which is a T score of -1.5 to -2.49.

It was explained to her the consequences of her lifestyle choices and the effects of what vertebral fractures can do to a person’s quality of life. No one wants to end up disfigured with the possibility of a Dowager’s hump which is not reversible. The individual reduced the amount of exercise she was doing to “normal levels”, which resulted in her periods returning, which assisted with her improvement of bone health, as her oestrogen levels returned to normal. She also learned some stress coping techniques that she could use at her office desk, as she had previously increased her running times in an attempt to decrease her stress levels.

After the menopause, the ovaries stop producing oestrogen and the adrenal glands produce the male hormone testosterone, which is then converted into oestrogen by the peripheral fat. When a person is underweight, they do not have enough peripheral fat to assist with this process. Oestrogen is necessary to help protect bone and to also help in the formation of Vitamin D and absorption of calcium. When Vitamin D levels are low, bone loss occurs which increases the person risk of fractures. The lesson to be learned is that prevention of breaking bones is much cheaper and less painful than just targeting the highest risk group for bone loss.

NOTE Depo Provera has been proven to cause bone loss, therefore unless a young person is very high risk to become pregnant, the Irish Osteoporosis Society (IOS) would recommend a different form of contraceptive.

Women lose bone leading up to the menopause, going through the menopause and the most significant bone loss occurs in the 10 years post menopause. In general, we can only assume that the more risk factors for bone loss a person has, the higher the bone loss they will experience.

1 in 7 women will get breast cancer and there is a breast screening service available. In an ideal world it would be wonderful if DXA scanning would become part of an overall health plan tied into a peri menopause screening, as 1 in 2 women aged 50 will break a bone from Osteoporosis in their lifetime.

Some people are of the belief that DXA scans place a person at high risk of radiation exposure, if you have heard this, it is not accurate. A DXA scan exposes a patient to 10% radiation of a regular Chest X-ray. A person flying from Dublin to New York will be exposed to more radiation than a DXA scan. DXA scanning is what the IOS, the Osteoporosis national experts recommend for the screening, diagnosing and monitoring of bone loss.

Do you want to be the person or a loved one of yours who ends up with multiple fractures which could have been prevented, as research shows that most fractures are preventable?

The Irish Osteoporosis Society believe that focusing on over 65’s is playing “Russian roulette” with people’s lives, especially women’s lives. On the top of page 40 (figure 2) shows why all women should be screened for bone loss. The results also show that when a person has been diagnosed with Osteopenia, which is the early stages of bone loss, they MUST be monitored. The reason monitoring is so important is because bone loss is silent, NO one feels bone loss. There are no signs or symptoms of bone loss and logically all disease’s should be monitored and the DXA scan results show the woman’s bone health in her spine had declined by 40% in ten years and 23% in her hips.

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The woman’s DXA scan results below (figure 3) show that she had a DXA scan done in 2012.

Her DXA results (aged 60) from 18 06 2018 show her bone density in her spine had declined 22.8% from her previous DXA scan which was done 6 years prior on 02 08 2012 (aged 54).

Her latest DXA scan results (aged 64) on 15 08 2022 show her bone density in her spine had

declined by 17.2% since 18 06 2018, in 4 years.

The graph in the image on the top of page 41 (figure 4) shows how her BMD (Bone mineral Density) plummeted from age 54 to 64.

Her DXA results from 18 06 2018 show her bone density in her hips had declined by 13.3% in 6 years.

Her latest DXA scan results in the image below on 15 08 2022 show her bone density in her hips had declined by a further 9.7% in four years.

The most significant results were from the LVA, which is a Lateral Vertebral Assessment which is a DXA side view of a person’s spine. This woman went through the menopause at 51.

The DXA LVA report at the bottom of page 41 (figure 5) shows she now has a T 5 Moderate Biconcavity fracture at T5 and T9 and a severe Biconcavity fracture at L1.

Could these fractures have been prevented? No one can say 100% yes. However logically, if she had been regularly monitored and when the initial bone loss occurred in

2018 her causes of bone loss had been investigated and addressed, there is a very high chance, the vertebral fractures could have been prevented.

Monitoring of bone health is essential, it is common sense. If a person had a heart attack, what cardiologist do you know would say “Come back in 5 years for a check up”. There are those who believe repeat DXA scans should be every 5 years. This woman is a prime example of why if a person has bone loss, they need to be regularly monitored.

Osteoporosis is not like most other diseases because there are no signs or symptoms prior to someone fracturing. Most people are taking treatments to suppress symptoms or slow down the progression of other diseases, Osteoporosis treatments have been proven to reduce fracture risk. It is essential to ensure a person is responding to their treatment and if a decline occurs switching a treatment should not be the first option. Investigating and addressing why their DXA scan results have declined or similar to the case above, investigating why they have fractured is crucial to help keep the person independent.

Cancer and Osteoporosis

Anyone who is going to receive chemotherapy or radiation for cancer should have a DXA scan done prior to the initiation of either treatment. If positive or negative for bone loss they should be put on a bone health plan, as both cause significant bone loss. If the person is negative for bone loss prior to the treatment, they need to be placed on an Osteoporosis treatment to prevent bone loss occurring. For a person to fight cancer to stay alive and end up with multiple fractures is not acceptable. Ireland is not a third world country and for any of you or your customers who have had either treatment or are on Medications like Arimidex or aromatase inhibitors, they need to be informed to get a DXA scan done.

Diabetes and Osteoporosis

There are two types of Diabetes Mellitus (DM). Type 1 which is a genetic disorder and people are usually diagnosed when they are young due to an insulin deficiency. Type 2 DM usually develops due to a poor dietary intake, and this usually develops over time. People with Type 1 and 2 DM are at risk of fractures due to Osteoporosis.

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Menopause and Osteoporosis

When a woman goes through the menopause, it is very important it is not assumed that this is the only cause of her bone loss, as there are approx. 200 other causes of bone loss.

Menopause and Bone Health Tips

• HRT should only be given to those who go through an early menopause before age 45, who do not have contraindications, and those who have menopausal symptoms.

• HRT should not be prescribed just to protect bone health.

• For those who are going through an early menopause HRT should consist of oestrogen and progesterone. Oestrogen only should not be prescribed unless they have had a hysterectomy.

• Premenopausal females who have low oestrogen e.g. due to an eating disorder, can be prescribed either the contraceptive pill, i.e, an oestrogen and a progestogen, or HRT, that contains a different type of oestrogen and progestogen but ensure to tell them that it is not a contraceptive.

• Post-menopausal women who have an early menopause before age 45, if they still have a uterus, should be prescribed HRT consisting of oestrogen and progestogen, because otherwise it can increase the risk of cancer of the body of the uterus.

• Post-menopausal women who have an early menopause before age 45, If they have had their uterus removed they can go on oestrogen only.

Severe bone loss

A T score of -3.0 or higher on a DXA scan report

• Avoid when possible, bending forward at your waist with legs straight

• Initially, no lifting anything over 3 pounds

• Put food items in a trolley and only half fill the bags

• Do not use a vacuum, stretch up for items, or twist your body to either side with your feet planted on the ground.

• No stretches or exercise that put stress on the bones in your back such as yoga.

• No lifting of children or pets in and out of a cot, car etc

• Raised garden beds are ideal for those who love gardening

Most people are not aware that fractures should be taken far more seriously, due to the secondary complications which can be life threatening, which are a blood clot, pneumonia or infection. 20% of those who fracture their hip aged 60+ will pass away within 6 to 12 months and 50% will lose their independence. Vertebral fractures significantly impact on activities of daily living, such as washing, dressing and walking.

A person can be diagnosed with Osteopenia and/or Osteoporosis. Osteopenia is the precursor to Osteoporosis, and it is essential that the reasons why a person has lost bone is investigated and addressed, not assumed.

NOTE A calcium and vitamin D supplement is not an Osteoporosis treatment. Calcium, vitamin D and first class proteins when ever possible should be from foods.

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Men and Osteoporosis

The diagnosis rate for Osteoporosis in men is very low and the IOS believe it is because of the myth that “Osteoporosis only affects old women”. 1 in 4 men over 50 will break a bone from Osteoporosis in their lifetime. More men pass away from Osteoporosis then get prostate cancer, which is why all men should be checking to see if they have risk factors for bone loss.

Exercise and Bone Health

Appropriate weight bearing exercise is very important for those with bone loss, as well as improving muscle strength and balance. A very common stretch done by people is forward flexion which is shown in the image at the top of page 42 (figure 6). The IOS does not recommend this stretch for anyone other than athletes due to the damage it can inflict on a person. This stretch puts excess compression on the front of the body of the vertebrae and strain on the discs between the vertebrae. This stretch also puts excess strain on your sciatic nerve in your back, that if irritated will cause pain to go down your leg.

The excess pressure on the vertebrae can cause Vertebral fractures. Professor Moira O’Brien who set up the first Osteoporosis clinic in Ireland as well as being the only Osteoporosis consultant in Ireland, has had patients in their 40’s who fractured vertebrae due to this stretch and the IOS have received helpline calls from people who have also fractured from this forward flexion stretch.

NOTE: Many stretches in Yoga place stress on the bones in the spine, which is why the IOS do not ever recommend yoga for those with and without bone loss.

We do not recommend the following for those with bone loss:

Touching your toes while in the sitting position or when standing bending forward at your waist, doing regular sit ups, exercise on trampolines, excessive weights, yoga, horse riding, skiing, twisting your back with your feet on the ground (golf swing), vibrating machines, high impact exercises such as jumping off boxes or heights or pounding your feet when walking. Jogging and running is not recommended for those who have vertebral fractures.

NOTE: The IOS does not recommend anyone with bone loss start an online exercise programme or weights programme, without having been individually assessed by a health care professional, who is up to date on bone loss. Why? To help reduce the risk of people getting hurt. In order for a health professional to put a person with bone loss on a safe and appropriate exercise programme, they must understand DXA scan results. A person can look perfectly fine but have severe bone loss.

We DO recommend the following exercises/activities for those with bone loss, but they may not be appropriate for everyone. It will depend on the person’s age, if they have broken any bones yet, their DXA scan results, medical history, causes of bone loss, balance, ability and age.

Walking, but the speed and course need to be altered.

Walking up and down stairs works the main muscles for walking, is great for your overall health and helps to build up bone in the hip area. So instead of listening to the adverts on TV or watching your partner switch from one station to another during the breaks, why not walk up and down your stairs a couple of times.

When it is raining or very windy outside. When the weather is very wet and windy, why not stand in front of your favourite TV programme and march on the spot while watching it or while listening to your favourite radio programme or walk around your home, including going up and down your stairs, as every step counts to help keep your independence.

Dancing, as long as you have good balance, and you are not being swung around.

Strength and conditioning programme, to include core stability. Senior citizens should start out actively exercising their limbs without weights. Light weights should be slowly introduced, as rushing to increase weights and resistance, can place a senior citizen at risk of muscle and joint soreness, which could turn them off exercising, and place those with bone loss at risk of possible fractures.

For those who had previously lifted weights, they should start with low weights and gradually increase.

Exercise in water can help build up muscle strength and endurance, without putting excess stress on joints.

Fall Prevention – Balance and coordination including ensuring your home environment is safe. Example – A good pair of walking shoes instead of wearing slippers, as most do not have good support

and no one should wear open back shoes as they are a tripping hazard.

Incontinence – There have been significant advances in the treatment for incontinence, which can lead to falls, due to people rushing to the bathroom or slipping on urine after having an accident, please contact the Irish Osteoporosis Society for more details.

Risk Factors for Bone Loss

Family history of Osteoporosis or broken bones (as 81% not diagnosed), menopause/ hysterectomy, corticosteroids, Chemotherapy, Radiation, Arimidex, Aromatase inhibitors, Physiological or psychological stress, RA, Protein pump inhibitors, eating disorders & over exercisers, low vitamin D levels, many medications for anxiety and depression.

Signs and symptoms of possible undiagnosed Osteoporosis

• A broken bone caused by a trip and fall from a standing position or less, even if on cement or ice.

• Many people believe that it is normal to lose height as you get older, it can be a red flag for undiagnosed vertebral fractures.

• A person’s head protruding forward from their body or their shoulders becoming rounded or a hump developing on their upper back can be sign that vertebral fractures have occurred.

• A person’s body shape changing, such as a pot belly developing, an increase in clothes size, or the person not being able to reach previously accessible shelves.

• Upper, middle or low back pain should be investigated, and Osteoporosis ruled out, as 75% of people with vertebral fractures have intermittent back pain. The image below (figure 7) shows the effects of undiagnosed/ untreated bone loss at any age.