A 74-year-old woman develops severe back pain after sneezing. She is brought to the emergency room by her family. An X-ray of the spine reveals that one of her vertebrae has collapsed by more than 50%. A 70-year-old man while making breakfast in his kitchen, trips over his cat, and lands on the floor and is unable to get up . His wife calls 911 and he is taken to the hospital where he is diagnosed with a hip fracture. He undergoes surgery and rehabilitation but months later he is still unable to return to his previous level of functioning
What these two patients have in common is condition known as osteoporosis , which literally means porous bone. Many people call this ‘ brittle bone disease ‘. Osteoporosis is a disease characterized by a decrease in bone strength. This decrease in bone strength leads to fragility fractures. Fragility fractures are defined as fractures that occur with minimal trauma, for example, a fall from the level of the floor resulting in a hip fracture.
In 2010 approximately 9.1 million American women and 2.8 million American men were estimated to have osteoporosis. A fifty year old woman has a fifty percent risk of an osteoporotic fracture in their remaining lifetime. The number of fractures due to osteoporosis is expected to rise to more than 3 million by 2025. An osteoporotic fractures occurs approximately every three seconds. It is common that osteoporotic vertebral fractures are never brought to physicians attention. These fractures can clinically present as self-limited back pain which eventually heals spontaneously. However, the presence of one vertebral fracture increases the risks of subsequent vertebral fractures by 500%. Seventy five percent of postmenopausal women in the United States did not receive treatment during the year following an osteoporotic fracture. Approximately 52,000,000 people in the United States have osteoporosis or low bone density. The vast majority of these people never undergo treatment to prevent fractures. Twenty percent of people with a hip fracture will die within one year. Osteoporosis is often silent disease until a fracture occurs. Silent diseases are often ignored by both patients and their health care providers. As result, the medical community can do a better job than it is currently doing to manage patients with osteoporosis.
Dual energy x-ray absorptometry (DXA) is a simple noninvasive x-ray test that is the standard for assessing bone mineral density. This test examines multiple bones in the body and compares it to a set of population data containing the peak bone mass as well as the average age-related bone mass. The results of this test can help determine an individual’s bone strength and thereby their risk of fracture. Once this is determined, those patients that would benefit the most from treatment intervention can be identified. Studies have shown that less than 15% of patients received a DXA scan post fracture.
Risk factors for osteoporotic fractures include increasing age, female sex, low body weight, previous fractures, parental history of hip fracture, rheumatoid arthritis, smoking, low bone mineral density, vitamin D deficiency, low calcium intake, increase risk of falling, immobilization, and certain medications such as glucocorticoids, cancer chemotherapeutic drugs, and anticonvulsants. In addition, there are patients with secondary causes of osteoporosis which can be treated. Secondary causes include a variety of conditions such as thyroid disease, hyperparathyroidism, osteomalacia, hypogonadism, etc.
How do you know if you might have osteoporosis? Signs and symptoms include loss of height, rounding and or deformity of the spine, back pain, and of course fractures that have occurred with a minimum amount of trauma.
At the present time, there are a variety of treatments and preventative measures for osteoporosis. Preventive measures include adequate calcium and vitamin D intake, weight bearing exercises, fall prevention and pharmacologic therapies. Treatments include both oral and injectable medications which can be tailored to a patient’s specific needs. Despite the availability of accurate screening technology and effective therapies, implementation of these measures for patients with fragility fractures remains inadequate.
Although there are a variety of physician specialties that care for patients with osteoporosis including primary care, rheumatology, endocrinology, orthopedics, obstetrics and gynecology, the real challenge is identifying patients who are at risk for fragility fractures, and treating those patients already fractured to prevent further fractures. A number of hospitals have developed programs to try to improve our treatment of patients with osteoporosis. At the John Heinz Institute For Rehabilitation Medicine in Wilkes-Barre, there is a re-fracture prevention program that helps discuss the issues of osteoporosis with those patients admitted with a recent fracture. The goal of the program is to reduce future fractures in those patients who have been identified with a high risk for fractures. These programs use a multi-disciplinary team to treat and work up patients after a recent osteoporotic fracture. Research has shown that these types of programs result in a 38% decrease in the hip fracture recurrence rate.
Knowledge can help build strong bones. Start with proper nutrition and appropriate exercise. If you are not being treated for osteoporosis and have several of the risk factors mentioned above, speak with your doctor. If you are being treated, make sure you are taking your medications correctly and understand their potential side effects. At risk patients, and patients being treated may need monitoring of their bone densities to ensure they are getting optimum treatment. And most importantly, if you have had a low impact fracture, speak to your healthcare provider to learn how to prevent this from recurring in the future.