After speaking at a recent seminar about the importance of exercise on bone health, it became more evident than ever that there is a big variation in the way people with osteoporosis and osteopenia are treated by health professionals. Clients’ levels of understanding about their bones vary dramatically too. This is a problem.
Given I’m a strong believer in the saying ‘knowledge is power’, I figured I’d pass on some of what came up to help you optimise your bone health management and treatment strategies. After all, fractures can lead to pain, disability, and a loss of independence. And we don’t want that if it can be avoided…and the good news is, it can.
Firstly, it is expected that 1 in 2 women and 1 in 5 men over the age of 50 are expected to break a bone in their lifetime. Pretty stark statistics don’t you think?
The most common places to have a fragility fracture is at the wrist, hip, or spine. When someone breaks a bone, it’s important for clinicians to work out whether the fracture/break, is expected (given the level of trauma i.e., a fall from a height) or if it is likely to be a fragility fracture (when the mechanism of injury does not match the level of trauma experienced i.e., slipping in the kitchen led to a fractured wrist). If the clinician/doctor diagnoses a broken bone as a fragility fracture, in theory, this ought to lead to further assessment and then treatment, but sometimes this doesn’t happen automatically.
Worryingly, spinal fractures are often found retrospectively and found on x-rays and scans when looking for something else. In fact, it’s estimated that 70% of spinal fractures occur ‘silently’. They can occur spontaneously or as a result of routine activities and people who sustain a vertebral fracture at one level are 5 times more likely to develop a further fracture at a different vertebral level. They are also 2-3 times more likely to sustain a fracture somewhere else in the body. This is why it’s important to know how to move safely, for instance when you’re gardening, and why we deliver bone health friendly Plus Pilates classes as a standard feature, regardless of whether you’ve been diagnosed as being osteoporotic or not. As a word of advice, if you attend classes/group exercise elsewhere, ask the person who’s leading the activity if they know about (and understand) osteoporosis. If they don’t, don’t go if you have this condition. It’s just not worth it.
What causes Osteoporosis?
There are many factors that influence our bone health. Women are immediately more susceptible due to the declining amounts of the hormone oestrogen as we age, which has a protective effect on our bones. This may be one of the reasons why some women choose to take hormone replacement therapy. Other factors include normal ageing (most people over 80 will have osteoporosis), smoking and alcohol consumption (which effectively poison our bone cells), a family history of the condition, prolonged corticosteroid use, thyroid problems, some rheumatological conditions, a history of eating disorders and/or low body weight, and a calcium and vitamin D deficiency which may be a consequence of dietary choices. Here’s a useful link about calcium, along with the Edinburgh Calcium Calculator which assesses whether you are getting enough in your diet: https://theros.org.uk/information-and-support/bone-health/nutrition-for-bones/calcium/.
A simple blood test (via your GP) can also evaluate your vitamin D levels, so ask for it to be reviewed if you suspect you could be deficient. We cannot absorb calcium into our bones without adequate levels of vitamin D, so it is an essential component when evaluating bone health. In some instances, people may need to take a supplement but it’s important not to start these without being assessed because over-supplementation can be as harmful as being deficient/insufficient.
How do I know if I should be checked for Osteoporosis?
People over 50 who experience a fragility fracture ought to be screened fully for osteoporosis, as should those under 40 when they have a significant fracture risk or if they have health conditions such as metastatic bone cancer or hyperthyroidism. Other secondary causes (such as breast cancer) can also affect bone density, so it’s important to raise your concerns about bone health with your GP/consultant. People with a low risk of fragility fracture should be advised to follow appropriate lifestyle advice in the first instance, but it’s important to understand that this risk can increase due to the factors listed above and may need reassessing in future. The www.theros.org.uk website is a useful point of reference for general advice and tips.
So, what does a good bone health assessment entail?
There are a few things we can do to assess bone health and fragility fracture risk. Firstly, a DEXA (or DXA – they’re the same) scan is considered to be the best diagnostic tool for osteoporosis screening. It is a painless scan (for which you need to be able to lie flat on your back for approx. 15 minutes. It is delivered with minimal radiation and costs around £40. This is a less than a standard set of blood tests so there isn’t really a good excuse not to refer you for one if it’s clinically indicated!
The most useful/clinically relevant areas to be scanned are the hips and spine, but some people (for instance those with a parathyroid problem) may need to have their forearm scanned instead. Also, bear in mind that for someone with osteoarthritis in their lower back and/or previous spinal surgery, this will skew the results and make them difficult to interpret.
It is good practice to have DEXA scans repeated at 3-5 yearly intervals (or sooner for some with complex health issues) and ideally on the same scanner so the radiologists interpreting the data can do something called ‘trending’. This helps to inform treatment and management options. So, if you have osteoporosis (or osteopenia) and haven’t had a DEXA within these timescales, have a chat with your GP and, if you can, go back to the same place as before.
The diagnosis of osteoporosis is established by the measurement of BMD. This refers to bone mineral density. BMD correlates with bone strength and is an excellent indicator of future fracture risk.
What’s the difference between Osteopenia and Osteoporosis and what’s a T and Z score?
This is what you’ll hear/read once you’ve had your DEXA scan. The T score compares your bone density to that of a healthy 25-year-old. The Z score compares your bones to others of the same age. Osteopenia is kind of like the step before being diagnosed with osteoporosis. It is a milder form of the same condition and indicates low bone mass. The T score for someone with osteopenia would be between -1.0 and -2.5 whereas a person with osteoporosis would have a T score of (or below) -2.5. For people with severe/established osteoporosis, they would have a T score of (or below) -2.5 but with the addition of 1 or more previous fractures. It’s worth knowing that, with the right bone health management, you could move from being osteoporotic to osteopenic. This is a significant step in the right direction so please don’t forget that the work you put in, week in week out, will be having a positive effect.
When should I have a spinal x-ray?
It would be good practice for the following people to be referred for vertebral imaging (spinal x-ray) which will also help determine whether the individual has previously sustained a spinal fracture. If it’s clinically indicated, both ap (forwards facing) and lateral (side) views of your spine from T4 to L5 ought to be requested. These refer to the levels of your vertebrae that need to be checked:
If any of the above apply to you, have a conversation with your GP or other healthcare professional (such as a chartered physiotherapist like us).
How likely am I to have a fragility fracture?
Another very useful assessment tool is the FRAX tool, which works out your risk of breaking a bone over a 10-year period. Once you have the DEXA result, you can input your data to calculate your level of risk. This data may be done by your GP or rheumatologist, but you can also do it yourself. Here’s the link: https://www.sheffield.ac.uk/FRAX/tool.aspx?country=1
