1. Thanks to osteoporosis
foundations such as the NOF and the rise of social networking, there
are more opportunities for patients to learn from one another using
online discussion groups now about bone health related issues.
Patients can offer helpful insights. However, patients should not give
out confidential information or expect to get an online diagnosis.
2. In 2002, medical
professionals were concerned about a patient’s risk of fracture
throughout their life. Today, doctors are often taught to only consider the patient’s
10-year probability of fracture. Will this help patients remain
fracture-free during their entire life?
3. Ten years ago, few doctors
recommended Vitamin D. Thanks to significant achievements in Vitamin D
research, a much higher percentage of doctors are advising patients to
take Vitamin D, and the recommended amounts have increased. As a
result, more people are now getting an adequate amount of Vitamin D.
4. In 2002, doctors relied on
their knowledge, experience, and the patient’s risk factors,
preferences and bone mineral density (BMD) T-scores to determine
treatment and preventive options for patients, and that worked well. Today, doctors are
taught to use a FRAX
tool calculator
to determine a patient’s 10-year probability of fracture in order to
make drug treatment decisions. Osteoporosis researchers, however, are
divided as to the value of the FRAX method of calculating fracture
risk. For example, there was a debate at
the 2012 annual meeting of the ASBMR (American Society for Bone &
Mineral Research) on whether or not FRAX is more useful than
individual risk factors for identifying patients who will experience
larger reductions in fracture risk with treatment. Dr. Dennis Black,
the supporter of individual risk factors, won the debate.
Unfortunately, the FRAX calculator has occasionally been used to deny or discourage
bone density testing or to suggest to patients that they needn’t be
concerned about breaking a bone.
For example, ten years ago, the FRAX calculator would have indicated
that I "only" had a 9% chance of a major hip fracture in the
next 10 years and a 0.6% chance of hip fracture. Based on those
percentages, I would have been told not to get a bone density test and not
to be concerned about a fracture but to just take calcium and
Vitamin D. If a primary care physician told me to exercise, most likely
I would not have been given advice about the type and amount of exercise
required to maintain bone. Fortunately, FRAX was not used then. About
ten years ago, the doctor at my mother's bone density test center told
me that I should be concerned about getting osteoporosis because
of my mother's early hip fracture and osteoporosis and my thin build. He
advised me to get a bone density test in my home town and to take action
to prevent bone loss. I followed his advice, got tested, took a lot of
steps to help maintain bone and was able to avoid the high amount of
bone loss that typically occurs at and around menopause, so I am in
favor of using the patient's risk factors, BMD T-scores and preferences
to make medical decisions.
5. It used to be relatively easy
to find a bone density test center in America. Because of decreased
reimbursements for DXA tests by doctors, many doctor-operated DXA
centers have closed, although hospital imaging centers continue to
offer DXA testing. Unlike the doctor-operated centers, whose
technologists often
discussed the results with patients and gave them preventive advice,
hospital imaging centers typically refer questions about the test
results to the patient’s doctor, even though patients seldom have an
opportunity to discuss the results face to face with their doctor
afterwards. What’s better for patients? --- To get information about
their bone health only from their doctor or to get it from both their
doctor and test center?
6. In 2002, hardly any hospitals
had established fracture prevention programs for patients with
fractures. Since then, the International Osteoporosis Foundation has
established a “Capture
the Fracture”
campaign in order to break the fragility fracture cycle; the
American Orthopedic Association has established “Own
the Bone” to
encourage hospitals to take steps to help prevent repeat fractures.
Even though more hospitals have secondary fracture prevention programs
now, most still don’t have them, but they should.
7. Ten years ago, hardly any
doctors recommended back strengthening exercise or physical therapy
for patients with compression fractures. Even though physical therapy
and back strengthening exercise is a first line of treatment for disc
problems and back pain and has also been found be effective in
preventing spinal fractures, back-strengthening exercise is still
seldom mentioned to patients with compression fractures even though it
could be very helpful.
8. In 2002, many women were told
at menopause to take steps to prevent bone loss, such as hormone
therapy. Getting a prescription for a bone density test at menopause
was easier than it is today. A January 2013 Journal of Bone &
Mineral Research (JBMR) print article confirmed that bone loss
increases significantly during the transmenopause phase and that it
begins before menopause SWAN
study article entitled “Bone Mineral Density Loss in Relation to the
Final Menstrual Period . . .” (pp 111-129)
Therefore, when a middle-aged
woman’s periods start becoming very irregular, this is a good time
for a doctor to warn women about the need to do more muscle
strengthening resistance exercise to offset the estrogen loss and to
take stock of their lifestyle and eating habits as well as their
calcium and vitamin D intake. Now that hormone replacement therapy is
less prevalent, it seems that discussions about peri- and
postmenopausal bone loss are less frequent. Shouldn’t
hormone-related bone loss prevention be stressed more now?
9. Ten years ago, bone health
recommendations for “safe exercise” focused on exercise that was
safe for osteoporotic patients with little concern for the prevention
of osteoarthritis and back and neck injuries in all people. Today
post-menopausal women are still being told by some osteoporosis
professionals to jump rope and hop on hard surfaces to increase their
bone density, thereby gradually damaging their joints. In addition,
patients with potential back and neck problems are being told to take
yoga and Pilates classes at gyms without being given any instruction
on which exercises to avoid in these classes. The concept of “safe
exercise” among osteoporosis professionals still needs to be
expanded to include the prevention of osteoarthritis and back and neck
problems even when patients don’t have osteoporosis.
10. The
medical establishment used to focus on having a high intake of milk
products and calcium as a non-drug means of preventing osteoporosis.
Even though they have always advocated having a well-balanced diet,
medical professionals are now emphasizing more the importance of other
nutrients besides calcium such as Vitamin D and the need to include
lots of fruits and vegetables for optimal bone health. They’re also
recommending that patients get most of their calcium from dietary
sources instead of supplements.
Many alternative practitioners, on the other hand, advised against
consuming dairy products saying that milk is for cows — not humans —-
and
citing studies showing that Asians, who consumed less milk, often had
fewer fractures. (However, Asian food is typically more nutritious
than western fast-food meals, and exercise and the vitamin D levels of
the participants were not factored into the studies.) Today some
alternative practitioners still discourage people from consuming dairy
products even though dairy is a good source of dietary calcium and
contains essential bone nutrients such as Vitamin B12, which is not
available from plants.
11. In
2002, if a patient had a slumped posture, it was unlikely that a
doctor would mention this and recommend posture and back strengthening
exercise during a physical. Today it is still unlikely that a doctor
will offer posture advice during a physical. In fact, posture and
back-strengthening exercise is not even mentioned in the Jan 2013 JBMR
article entitled “Factors
Associated with Kyphosis Progression in Older Women”
(pp179-187). However, the
article does state: “Hyperkyphosis,
or an increased thoracic curvature, is commonly observed in older
persons affecting up to 40% of older women . . . Although the
development of age-related kyphosis is often attributed to underlying
spinal osteoporosis, only 36% to 38% of those with the most abnormal
kyphosis have underlying fractures.”
Fortunately patients can go to their local gym, where some teachers or
trainers will point out their stooped posture, telling them it is
caused by being slumped for hours in their chairs at work and at home.
The teachers will then give them practical advice on improving their
posture, something that was absent from the JBMR article; gym
participants will be told to pull their shoulders back and down, tuck
the tummy, pull the butt in and do
the exercises with proper form and posture. It’s amazing how the
posture of the entire class can immediately improve with this simple
advice. It’s good that researchers are making us more aware of the
need to address the topic of kyphosis.
12.
Ten years ago, osteoporosis-related conferences usually relegated
exercise information to a pre-conference session and/or a concurrent
session alongside sessions with non-exercise topics. This year the NOF
has devoted an entire plenary session to exercise options so that all
participants learn how to use exercise to help patients. This is
welcome news.
For more than twenty years, we’ve had specific information about the
types of exercise required to prevent bone loss. Dr. Sydney Lou
Bonnick, whose bone densitometry books are standard ISCD
(International Society for Clinical Densitometry) texts, also wrote The
Osteoporosis Handbook (1994), which outlined the types of exercise
required for maintaining and building bone. She backed up her advice
with research. Yet, there are still doctors telling patients that all
they need to do to maintain bone is to go out and walk a few times a
week; this is because the doctors haven’t received adequate exercise training in medical school or at conferences.
On page 74 of The Osteoporosis Handbook, Bonnick highlights the
paragraph “Exercise is site specific. If you want a strong spine,
you must exercise the spine. If you want strong legs, you must
exercise the legs.” Even though this is common sense, many doctors
don’t understand the need for site specific exercise for maintaining
bone and are surprised when significant variations of BMD T-scores
occur in different areas of the skeleton. Additional exercise
information is available at www.avoidboneloss.com/exercise.htm.
A September 2012 JBMR article (pp1896-1906) stated “astronauts who
have access to sufficient resistance exercise, coupled with adequate
energy intake and vitamin D status can return from spaceflight
missions of 4 to 6 months with measured bone mass and BMD’s
seemingly no different from baseline measures—for most skeletal
regions” (p 1900). The article was entitled: “Benefits
for Bone From Resistance Exercise and Nutrition in Long-Duration
Spaceflight: Evidence from
Biochemistry and Densitometry.”
Even though the exercise prescribed for earlier flights was inadequate
for preventing bone loss, this did not discourage space officials from
experimenting with other exercise regimens to find a more effective
means of preventing loss. They kept experimenting until they found
something that worked. We should take the same approach to finding
non-drug methods of preventing hormone- and age-related bone loss.
,
from the Institute for Neurosciences at Northwestern University Medical
School also suggests that a proper balance of magnesium and calcium
could be important for preventing negative side effects from calcium
supplements.
Consider
including information on how to interpret medical reports in high-school
biology and health courses. Then students could better understand the
effects of their lifestyle on their health when they examine their blood
results and other medical tests. If proper nutrition is not part of
the biology or health curriculum, that should also be included.
Include
instruction on how to use free weights and weight machines in physical
education classes. I had to pay a trainer to learn this, but many people
can’t afford a trainer. Strength training is not only helpful for
maintaining bone, it is especially effective for preventing sarcopenia
(muscle loss).
Eliminate
the requirement for the DXA bone density test for self-pay patients. I
know three people who wanted to pay for a bone density test but had to
switch doctors in order to get the test done. A colleague of mine, whose
mother had osteoporosis, was told by her doctor to just take calcium and
walk fifteen minutes a day three times a week and to accept the fact
that we all have our genes and we can’t fight with them.
There
is an easy solution to the dilemma doctors face of either being accused
of ordering unnecessary tests or else alienating a patient by refusing
to write a DXA prescription—eliminate the requirement for a doctor’s
order for self-pay patients. No other screening test in America requires
a prescription if the patient is willing to pay for the test. Federal
law prohibits requiring a prescription for a screening mammogram even
though it has about 20 times more radiation than a DXA scan. You can get
almost any type of blood test through the Internet without a
prescription. Lifeline Screening makes a lot of money by offering
carotid and aortic ultrasound screenings, and no prescription is
required. Screening CT scans of the heart, lungs, colon and full body
are available without a doctor’s order and so are MRIs. It’s hard to
understand why the DXA community would want to limit their income by
requiring that self-pay patients get a doctor’s order for a DXA
screening of their hips and lumbar spine.
Some
medical associations are telling doctors that bone density tests are not
cost-effective before the age of 65 unless the person has had a
fracture, cancer or is on corticosteroids. It’s true that if the test
results are not discussed with the patient, as is so often the case, the
test is not worthwhile. In addition, if it is only used to prescribe
drugs, then the full benefits of the test are not obtained. NASA and the
army have used DXA testing to help develop non-drug methods of
maintaining bone, and so can individuals. DXA computer images can also
provide a lot of helpful information about the skeleton and can indicate
the onset of osteoarthritis and disc problems. One radiologist told me
that DXA scans have even been used for the early diagnosis of cancer,
allowing patients to get treatment before more serious problems
developed. Hopefully, in the next
decade, DXA professionals will take steps to ensure that all self-pay
patients who want information about their bone density status are able
to get a DXA scan, regardless of their age or risk factors.
Many
osteoporosis professionals are frustrated with the lackadaisical
attitude in the medical field towards the prevention of fractures and
osteoporosis. Positive change has occurred in the past decade, but more
can occur if we actively lobby for change. Below is a summary of some of
my suggestions for improving lifetime bone health:
♦
Care more about the lifetime risk of fracture instead of only the
ten-year probability. Why wait until the age of 65 to address issues
such as postmenopausal bone loss? Bone and muscle loss prevention
should start early in life..
♦
Encourage more hospitals to develop fracture prevention programs.
Orthopedic departments should consider establishing on-site or
off-site exercise programs as cardiology departments have done.
Primary care physicians should have a list of places where they can
refer patients for affordable exercise guidance.
♦
Expand the concept of “safe exercise” in the osteoporosis
community to include the prevention of osteoarthritis and back and
neck injuries for all patients.
♦
Include physical therapy and/or back strengthening exercise as part of
the treatment protocol for compression fractures instead of limiting it to
drugs and/or surgery.
♦
Take action at perimenopause to help women avoid hormone-related bone
loss. Perimenopause is a good time for women to get a baseline bone
density test, measure their muscle strength, and establish a program
to help maintain their level of bone density and muscle strength,
which in turn affects bone strength. In some cases, drug therapy is
warranted. One positive example is the Danish study "Effect
of hormone replacement therapy on cardiovascular events in recently
postmenopausal women": in the October, 9, 2012 British Medical
Journal.
♦
Include posture advice during physicals when needed. Recommend
back-strengthening exercise. Strong back muscles, posture exercise and
an awareness of one’s tendency to slump can help prevent kyphosis,
which in turn may create back pain and heart, breathing and digestive
problems.
♦
Include courses on nutrition and exercise as part of the required
medical curriculum for doctors. Also offer this information at medical
conferences.
♦
Eliminate the DXA imaging center protocol of
refusing to discuss test results with patients. Patients need more
information than what they typically get from their primary care
physician in order for the test to be useful. At the very least,
online information should be available. I’ve been told that Kaiser
patients can get all of their medical reports online or via e-mail,
and sometimes they get their results the same day of the test. The
report is identical to that which the doctor receives. It’s not a watered down
version saying, for example, “your results are in the normal range.”
♦
Help DXA centers stay in business by allowing self-pay patients to get a
DXA bone density test without a doctor’s order. It should be just
as easy for patients to get a bone density test as it is a mammogram, if
they pay for the DXA test themselves.
♦
Provide high-school students with the opportunity to learn about
nutrition, resistance exercise and the meaning of their medical test
reports. Some students are unable to get good nutrition or health
advice at home.
The
above steps could go a long way in helping prevent fractures and
improving the overall health of patients.
