Chronic Pain

Osteoporosis

Osteopenia and osteoporosis are conditions that occur when the body doesn’t make new bone as quickly as it reabsorbs old bone. There are two types of bones. There are the long bones, such as the arms and legs, which contain cortical or dense bone. The other type is trabecular bone, which is more porous or spongy, and found in the spine, hips, and wrists (among other areas). Trabecular bone allows us to flex, and acts as shock absorbers (similar to the areas between the vertebral bodies- read here).

Bone loss is tested by a bone mineral density (BMD) text. It uses a minimal amount of radiation exposure and a dual x-ray absorptiometry, or DEXA scan. It is a simple, non-invasive, non-intrusive, painless, 20-minute test that can be done in a radiologist office while fully clothed. The procedure looks at the areas most prone to break down, such as the spine (where break down leads to compression fractures) and hips and determines a risk factor. For the results of your scan, you’ll get a T-score. It shows how much higher or lower your bone density is than that of a healthy 30-year-old, the age when bones are at their strongest. The lower your score, the weaker your bones are considered. A T-score of -1.0 or higher is normal. A T-score between -1.0 to -2.5 is osteopenia. A T-score of -2.5 or lower is defined as osteoporosis.

Fracture risk increases as bone mineral density declines. A study published in the Journal of the American Medical Association in 2018 reported that a 50-year-old white woman with a T-score of -1 has a 16% chance of fracturing a hip, a 27% chance with a -2 score, and a 33% chance with a -2.5 score. According to this study, hip fractures are among the most devastating consequences of osteoporosis. Hip fractures are associated with a substantial loss of independence, limitations in ambulation, chronic pain and disability, loss of independence, and decreased quality of life. It also increases the risk of admission to extended care facilities, morbidity, and mortality. A shocking 21-30% of patients who experience a hip fracture will die within one year.

We can identify those with high risk of osteoporosis by using “s.c.o.r.e.”–a simple calculated osteoporosis risk estimation. That is defined by age, weight, race, estrogen use, previous fractures, and rheumatoid arthritis. The rate of bone loss varies from person to person. But around midlife, bones become thinner. How fast or how slow you lose bone depends on a number of factors:

• Your activity level- increased activity levels and exercise decrease risk

• Your family history- if your family has osteoporosis, you’re at higher risk

• Certain medications

• Race- White and Asian women have the greatest risk.

• Age- The chances are higher for women over 50 and go up with age.

• Weight- Thin women are at higher risk.

• Smokers- People who smoke lose bone thickness faster than nonsmokers

• Lifestyle habits-alcohol consumption increases risk

• Rheumatoid Arthritis- Studies have found an increased risk of bone loss and fracture in individuals with rheumatoid arthritis. The glucocorticoid medications often prescribed for the treatment of rheumatoid arthritis can trigger significant bone loss. In addition, pain and loss of joint function caused by the disease can result in inactivity, further increasing osteoporosis risk.

• Early menopause- Women who went through it before age 50 have higher chances of getting osteoporosis. Estrogen is important for maintaining bone density in women. When estrogen levels drop after menopause, bone loss speeds up. This can happen with natural menopause or an early surgical menopause if you have your ovaries removed. During the first 5 to 10 years after menopause, women can lose about 2.5% of bone density each year. That means they can lose as much as 25% of their bone density during that time. Accelerated bone loss after menopause is a major cause of osteoporosis in women. For women, having the strongest bones possible before you enter menopause is the best protection against debilitating fractures.

• Men also get osteoporosis. In fact, about 2 million men over age 65 have osteoporosis. Osteoporosis usually starts later and progresses more slowly in men. Still, osteoporosis in men can be just as disabling and painful as it is in women. According to the article in JAMA, one in five men, 50 years and older will experience an osteopathic fracture in his lifetime. Mortality after hip fractures is higher among men than women.

Screening with a DEXA scan is an effective means of identifying high-risk individuals. According to the National Osteoporosis Foundation, screening for men is now targeted for 70 years and older, and women 50 and older. Fracture prevention is the ultimate goal, and a bone DEXA screen is an affective, low-cost means of identifying men and women at high-risk. Research shows that clinical risk factors are also important because individuals with the combination of a low bone DEXA score and an increasing number of risk factors have the highest incidence of hip fractures.

Screening must be followed with effective treatment and fall prevention. There are many potential treatments such as biophosphates (like Fosomax or Boniva) which can be taken weekly or monthly, as well as other treatments that can be injected once or twice a year. Other options include a hormone-based daily pill (Evista), and a nasal spray, (Calcitonin). There are side effects to any of these treatments- discuss with your healthcare provider which one is best for you. Knowing how to minimize, prevent, and treat osteoporosis will keep you healthier, safer and stronger. Next Friday, we’ll discuss effective ways to help decrease the likelihood you’ll develop Osteoperosis- check back!

-Dr. Courtney

Main image courtesy of epainassist.com

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