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Osteoporosis

Osteoporosis

One out of ten persons suffer from osteoporosis in Hungary

Most persons appear for osteoporosis treatments only after having suffered specific fractures, or, not even then. It is important, therefore, that we conduct informed prevention programs for the persons at high risk of fracture. Under the auspices of the National Osteoporosis Program, we have initiated such a program at several Osteoporosis Centers in conjunction with other specialties, for the examination and treatment of patients suffering from osteoporosis. Rheumatologists and endocrinologists also provide complex osteoporosis treatments and medications. My intent here is to pass on my experiences and knowledge gained during several years of practice, in the hope of helping you avoid bone fractures.

Facts

  • In Europe, the USA and Japan, 75 million people live with osteoporosis.• In Hungary, 600,000 women and 300,000 men have osteoporosis
  • Even with the availability of state-of-the-art diagnostic procedures and modern effective preventive therapies, only 8% to 10% of patients are treated for osteoporosis (latter 2008 data)
  • Sixty to eighty percent of patients undergoing medication treatments will be able to stop taking the medications within one year (international data)
  • Of the 50 year old population, 46% of the women and 22% of the men may count on having a fracture characteristic of osteoporosis at some point in the latter part of their lives
  • Between 1990 and 2000, the incidence of hip fracture in the world increased by 25%.
  • By 2050, a precipitous increase in hip fracture is anticipated worldwide. An increase of 240% expected in women and 310% in men
  • According to a European data, the mortality rate following hip fracture is similar to that of diabetes, breast cancer and chronic obstructive respiratory disease (COPD)
It is estimated that more than 3000 persons per year pass away as a result of complications of hip fracture in Hungary and only about 25% of them may anticipate their condition following rehabilitation to be similar to that prior to the fracture.

Osteoporosis is an Endemic Disease

The expected life span at birth has increased significantly, principally, as the result of the many advances in medicine. As we age, changes in the natural hormone levels, absorption and the gradual decrease of organ function result in the loss of bone mass. These, even on their own, explain bone loss as the result of aging. (The average age of the Hungarian population is, unfortunately, well below that of the European Union, but, higher than that of the early 1900’s.) Several risk factors have appeared in our surroundings. Basically, our life style is sedentary, the population’s calcium intake, instead of the preferred 1000-1500 mg. per day, is 400-600 mg per day and several hundred thousand persons are vitamin D deficient.

Side effects of certain medications, such as steroids (bronchial asthma, allergies, skin diseases, joint diseases), certain epilepsy medications, thyroid hormones and anticoagulants may result in bone loss after prolonged use. The overuse of alcohol and excessive smoking as well as the consumption of the ever more popular carbonated drinks rich in phosphates are a serious problem in Hungary. Our stressful life style, the irregular meals and often unbalanced diet is also not optimal for building bones. The good news is that our diagnostic possibilities have greatly improved and with the added technical capabilities more examinations are possible resulting in a higher rate of findings.

Typical symptoms of osteoporosis

it is a mistake to think that osteoporosis is always symptomatic!

Most cases of osteoporosis are asymptomatic right up until the first fracture. It is often called the silent epidemic or smoldering disease. Along with the loss in height, the increasing curvature of the back, the decreasing distance between the ribs and the ilium, the appearance of transverse folds on the torso and musculature and the sagging stomach wall may already be indicative of vertebral body fracture.Typical fractures most often occur following trivial falls, coughing, sneezing and when lifting heavy objects.

The following are the yearly fracture incidences in Hungary:

  • Hip region (12,000 -14,000)
  • Vertebral bodies (30,000 - 40,000)
  • Wrist (35,000)
  • Upper arm (12,000 -14,000)
This is roughly comparable to everyone in a town the size of Székesfehérvár having suffered a fracture in 2011. The data is shocking, yet, in spite of this, the number of persons taking part in osteoporosis preventive medication treatments is less than the number of persons that suffered typical fractures during a given year.
Another bigger problem is that having suffered a fracture once, the risk of a new fracture is increased: one quarter of persons with vertebral body fractures will again suffer a fracture within one year!

Fifty-five percent of women between the ages of 50 and 60 years who have suffered a wrist fracture may expect some type of new fracture within 10 years and 80% of them, within 20 years.

Please, think of those around you when you read these lines and let them know of these facts. Should an older person have suffered a fracture, ask them whether they know the cause of the fracture? Have any preventive measures been taken?

Complications of Bone Fractures

Most bone fractures are suffered by the elderly. Their already weakened system is much more susceptible to trauma, resulting in complications even with the best medical care. The also suffer more often from circulatory and respiratory problems, pneumonia, deep vein thrombosis, pulmonary embolism, decubitus (bed sores), bladder infection, pseudoarthrosis, deformities and pain due to bone fracture, etc.

The lack of exercise often results in multiple complications leaving the patients feeling shut in, turning inwards and defenseless. Caring for themselves and taking care of their affairs may also cause difficulties. Oftentimes, they cannot leave their homes ending up isolated and shut off from the outside world.

Unfortunately, most countries do not have fracture prevention programs. Typically, according to Hungarian data, one-third to one-half of those who have suffered bone fractures following a trivial fall did neither undergo an examination nor take part in a bone fracture risk reduction program

Osteoporosis risk factors

In 60% to 80% of cases, genetics is the cause of osteoporosis, while 20% to 40% of the cases are caused by external factors. The reason that it is important to know the risk factors is so that the elimination of the possible risk factors equally constitute the elemental parts of prevention and treatment.

The principal risk factors

  • Advanced age
  • White
  • Female
  • Excessive coffee, phosphate rich carbonated drinks and alcohol intake
  • Sedentary life style
  • Smoking
  • Early gray hair
  • Short in stature and low in weight
  • Hip, vertebra, wrist or upper arm fracture following a minor fall
  • Existing osteoporosis in the family, typical fracture
  • Early menopause (less than 47 years of age)
  • Chronic gastrointestinal disease, absorption disorder
  • Chronic kidney and liver disease
  • Thyroid, parathyroid, adrenal gland, sex hormone disorders
  • Steroid medication (asthma, allergies, immune disorders, skin disorders, inflammation of joints)
  • Epilepsy medication
  • Anticoagulants
  • Organ transplantation
Bone densitometer examinations have been available in Hungary for several years for persons of high risk of fracture with a doctor’s referral. The examination is available at the Buda Health Center where you can be examined with the most modern equipment (GE Prodigy) in but a few minutes, in elegant surroundings, for a fixed price.

Osteoporosis and Bone Densitometry

The osteodensitometry test is part of the basic clinical examination. Ultrasound and x-ray equipment is used, the results then compared to that of a healthy control group. The radiation loading is extremely safe, the process painless, requires but a few minutes while you are resting either in the sitting position or lying down. In everyday practice, beside the peripheral measurements (wrist, finger phalanges, ankle region), the central measurements (vertebrae, hip region) also play an important part.The densitometer measures the mineral contents of your bones with the results usually given in g/cm2. These values are compared to that of a healthy control group with the degree of reduction from the mean known as the T-score.

On your report, the level of decrease will be shown by the T-score representing the number of units, called standard deviations (SD), with each unit signifying a 10%-12% bone density variation and at least two times greater risk of fracture in the region concerned.
  • When the T-score is above -1 SD, the bone density is considered normal.
  • When the T-score is between -1 and -2.5 SD, the bone density is considered moderately decreased (osteopenia).
  • When the T-score is below -2.5 SD, the mineral contents of the bone are definitely decreased (osteoporosis).
  • In cases of moderate decrease, usually prevention, while in cases of definite decrease, treatment becomes necessary. It is important that the measured values be interpreted along with other risk factors.










Illustration shows a patient with definite decreased bone mass.

DEXA. T-score below -5, signifying a 50-60% decreased bone density when compared to a 30-year-old healthy person. Extremely great risk of fracture (the patient had already suffered several vertebral fractures).

X-ray examination of osteoporosis with typical fractures
Patients regularly present with medical and x-ray reports saying that they have osteoporosis. In reality, x-rays only show bone loss when there is more than a 30-40% decrease in bone mass and even that is mostly subjective making x-rays unsuitable for diagnosis and for checkups while undergoing medicinal treatment. The instrumental measuring of bone density with the densitometry may also be determined in percentages.
X-rays are excellent for recognizing fractures, for determining the extent of osteoporosis and for ruling out certain unusual bone diseases. They are also excellent for diagnosing degenerative disorders, calcification and narrowing of the intervertebral space in Patients who come to us with complaints of back and/or lower back pain. Problems independent of osteoporosis are often recognized and then treated, as a result.
Laboratory Tests
The laboratory tests help us identify the characteristics and the causes leading to osteoporosis. Through the blood test and urinalysis, we obtain information regarding the degree of bone loss, hormone levels, vitamin D level and excessive calcium discharge. The laboratory test is a help in choosing and initiating a personalized therapy program as well as in determining the effectiveness of a medicinal treatment that, in only two months, may show positive results thus helping the discipline needed for the treatment and the cost effectiveness. Following the first checkup, when the medicines have been adjusted, the laboratory tests are usually repeated yearly thereafter.
Osteoporosis treatment
1. Non-medicinal therapy
The foremost step to be taken is to leave behind the possible risk factors that were identified in your life. This step, of itself, may mean as much as a 40% reduction in your bone fracture risk. Another risk factor worth mentioning, is the non-active life style .
The basic osteoporosis therapy:
The daily minimum intake of calcium is set at 800-1200gm for children, 1200-1500mg for adolescents, 1000mg for adults and during menopause, 1000-1500mg. Hungarian data shows that the average daily calcium intake is 400-600mg (mostly in the form of bread), which, in the best of cases, is only one third of the required amount. If your daily intake does not meet the requirements, you should consult your doctor regarding oral supplements.
Vitamin D is also of basic importance in the building of bones. Its biological effect extends to the immune system, the cardiovascular system, the skin, the muscles, the pancreas, the liver and cartilage. We must think of vitamin D deficiency in cases of colon and breast cancer, prostate cancer, psoriasis, diabetes, diseases of the cardiovascular system and dementia, since the lack thereof, may require treatment.
The importance of physical activity:
One of the strongest stimulants for activating bone building cells is physical activity. With every single movement we make, the tendons of our muscles pull and move our bones thereby stimulating the bone building cells. Bone mass reacts to and changes with weight bearing, thus, physical activity is essential in our younger years for increasing bone mass and in our older years for maintaining bone mass. Fast walking, jogging, gymnastics, aerobics, dancing, or, actually, any activity that loads the spine in the upright position will be of benefit.
Every patient should also be taught physiotherapy since it helps coordination and provides stable muscle support for the body. Besides osteoporosis, patients often suffer from degenerative spinal diseases and increased wear. Several months of hard physiotherapy work and the strengthening of the spine muscles, may make it possible to decrease the back complaints.
Treating accompanying diseases:
In order to anticipate and prevent a person from falling, it is important to regulate fluctuating blood pressure, adjust blood sugar values and take care of hearing and eyesight disorders. Sleeping pills and tranquilizers are often the source of serious problems, often causing dizziness and, consequentially, falling. Dizziness is a serious risk factor for bone fractures. For the person suffering from osteoporosis, whose bones fracture as the result of a very minor fall much easier than that of a normal person, falling should be avoided at all costs. Pain due to orthopedic diseases may also often cause a patient to fall since the degeneration of the hip, knee and ankle joints may cause pain when attempting to walk causing the patient to fall as a result.
Health aids:
The use of a cane or a walker may prevent falls since they offer stability and security and decrease weight bearing on a given side. Special hip protector pants may help prevent hip fracture in a fall. A pillow surrounding the hip may help distribute a sudden strong impact, decreasing the force directed on a given point and, thus, possibly avoiding hip fracture. The spine corset may be of great help in decreasing the load on the spine. Instructions should be given, since it may be uncomfortable and will not have the desired affect, if not worn properly. The spine corset should not be worn continuously since it weakens the muscles – a maximum of 2-4 hours is advisable. When used following a new vertebral fracture, the spine corset makes almost immediate mobilization possible and in cases of degenerative diseases, it helps in the daily household duties and in caring for ourselves. (Illust.)
Ideal home surroundings:
It is very important that all frequented areas of the home be well lighted and free obstacles. Night lights are also advisable as well as slip proof pads under rugs or the slip proof rugs that are available now. Floor wax should be avoided. Handle bars should be installed throughout the house, especially in the bathroom. It would be helpful to have a flashlight handy in case of a power failure and a telephone in several places. By organizing our home well, we can prevent a fall.
2. Medication therapy
When speaking of medication therapy, we should differentiate between medication that serves to boost bone building from that which inhibits bone breakdown. Calcium and vitamin D supplements are necessary in each case in the amounts determined for each person.
The medication that boosts bone building works by stimulating the bone building cells to decrease the incidence of bone fractures and to increase bone mass.
As far as the bone breakdown inhibitors are concerned, we now have many more medications to choose from. They work by slowing down the accelerated bone breakdown, decrease the number of hollows left by the bone breakdown cells, thus, opening up the way for the bone building cells to create additional bone mass.
There are many osteoporosis clubs in Hungary where doctors hold lectures once a month on a regular basis and where patients may exchange ideas and give each other advice on the disease in a friendly atmosphere. Group physiotherapy is also available at a number of locations.
Our Osteoporosis Clinic offers a complex treatment following a physical examination.
We wish you good health and a long life free of fractures!
We are here to help you!
Peter Somogyi, MD
Orthopedics, Physiotherapy, Musculoskeletal Rehabilitation