How COVID Has Impacted Bone Health and What You Can Do About It Right Now

How COVID Has Impacted Bone Health and What You Can Do About It Right Now

From YouAreUNLTD by Feel It In Your Bones

Osteoporosis is often described as “a silent disease.” During COVID, this has never been more true. Bone health took a back seat. Health assessments, bone density testing and sometimes treatment itself were upended by the pandemic. This disruption in care may have serious, long-term consequences for patients.“The impact is going to be seen both immediately and down the line, as we see people not getting diagnosed, not getting treated,” says Dr. Vivien Brown, a family physician, assistant professor with the department of family and community medicine, University of Toronto. “And ultimately, we may see an increase in fracture risk and fracture rate. And now, six months into COVID when we’re referring patients for bone density tests, there is a backlog.”

Screening for osteoporosis is critical, according to Dr. Brown, especially for women over the age of 50. More than breast cancer, more than heart attacks or stroke, women are most likely to experience a fracture due to weakened bones. Medical intervention to prevent or treat osteoporosis, as well as the adoption of healthy lifestyle behaviours, may be needed. Failing to diagnose the disease can lead to serious outcomes.

“Until they’ve had a fracture, until they’ve had an event, people don’t really have osteoporosis on their radar as a concern,” explains Dr. Brown, who just updated her book, A Woman’s Guide to Healthy Aging (to be published in January 2021). When COVID hit, the focus for healthcare was on providing essential services only. Bone density testing was not considered essential.”

Long-term consequences of the care gap

These interruptions have caused a care gap, making incidents like hip fractures an even greater concern. The research is alarming – 28 per cent of women and more than 37 percent of men over the age of 80 die in the first year after a hip fracture. “It can be a life-altering event, if not a life-ending event,” she says. “We really need to still maintain our level of vigilance around osteoporosis. And I don’t think that’s happening day to day in the medical community.”

Furthermore, she points out that hip fractures can become family tragedies, according to Dr. Brown. “Some patients can’t return home to live independently. They may not be able to walk without assistance. They may not ever be able to drive again. It really alters their quality of life, which impacts the entire family…. The way I think about osteoporosis is that it is not just a bone disease. Osteoporosis is your independence on the line.”

As the impact of COVID has rippled across the country, continuity of care for osteoporosis patients has suffered. For those who were prescribed injectable medications, missed shots were an issue. “The consequences are really significant because the benefits of an injectable medication are completely reversible,” points out Dr. Brown. “That means when you get past that six-month window where you’re supposed to get your next injection, if you go more than a month or so, you start to reverse the benefits you’ve had because the drug is out of your system. That reversal actually increases your risk of fracture. It’s really important to stay on schedule with this medication. It means being creative – either seeing your doctor for the injections, getting it from a pharmacist, or learning how to self-inject. Just delaying an injection is not acceptable.”

During COVID, the focus on osteoporosis decreased. Good lifestyle habits also waned as people stayed home. Sedentary behaviour and poor dietary habits increased, while the ability to exercise in a gym and access to healthy food was negatively impacted. “A number of my older patients who live at home alone and don’t want to go to the grocery store are not eating healthy diets,” she says. “And if they’re not checking in with their doctor and not being reminded of what they need to do – something gets forgotten or left by the wayside.”

“The Way I Think About Osteoporosis Is That It Is Not Just A Bone Disease. Osteoporosis Is Your Independence On The Line.”

Issues with fracture follow-up

The pandemic has had a profound impact on our social support systems, too, especially when someone goes into the hospital with a fracture. Due to safety protocols, they cannot have their partners or someone else with them to be present to listen to a doctor’s instructions post-discharge. It’s concerning to Dr. Brown who fears that something will be overlooked. “If you’re in the hospital by yourself, it may be scary and you may be in pain,” she says. “You may not hear what the doctor is saying clearly. You get your cast or have the fracture treated, then get sent home. I don’t know that people are getting good follow up care.”

That lack of follow-up has a direct impact on continuity of care – a key component in successful osteoporosis management. “In some ways, osteoporosis is like hypertension. Patients often don’t feel it,” she notes. “Maybe they take their drugs for a couple of months, but then stop taking them if the meds are not easily accessible, if they don’t understand them, or not feeling the impact of the disease… It’s important to adhere to whatever has been prescribed.”

Now, it’s time to get back on track and to make bone health a priority again. How do we do that? Here are a few pointers from Dr. Brown:

6 ways to get back on track with your bone health during COVID

  1. Contact your doctor for a health review, which should include a discussion of osteoporosis prevention and ensuring you’re up-to-date with any medications to treat the disease.
  2. Let your doctor know whether you’ve had a recent fracture. A fracture may need to be investigated further to rule out osteoporosis as an underlying cause.
  3. Take an easy online test to determine your risk of a fracture. The FRAX fracture assessment tool can be done in just a few minutes and will look at key factors to calculate how likely you are to experience a fracture in the next 10 years.
  4. Have your risk for osteoporosis assessed by a healthcare provider. Factors that heighten your risk include: low body weight, family history of osteoporosis or broken bones from a minor injury, lifestyle behaviours (smoking, having three or more alcoholic drinks a day, and being sedentary), certain medical conditions (like rheumatoid arthritis), being a woman over the age of 50, and certain medications.
  5. Ask your doctor or pharmacist whether it’s time to schedule a bone density test. It is recommended that all women and men over age 65 have routine bone density tests. Men and women from the age of 50 to 64 with risk factors for fractures should also be tested.
  6. Resume good habits, like eating a diet with adequate vitamin D and calcium, exercising and sitting less.

 

 


New Mexico Orthopaedics is a multi-disciplinary orthopaedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.

New Mexico Orthopaedics offers a full spectrum of services related to orthopaedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.

Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopaedic condition, and offer related support services, such as physical therapy, WorkLink and much more.

If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300.

Did You Know That Inactivity is Actually HARD On Your Knees?

Between working from home and being glued to the television watching the latest election updates, many of us are guilty of increased “couch potato” behavior lately.  And we’ve all heard of the dangers of sedentary lifestyles contributing to obesity, etc.,  but did you know that *not* moving can actually weaken your knees and increase your chances of osteoporosis?

Continue reading for more from Noyes Knee Institute and the Journal of Public Health.

From Noyes Knee Institute

Do you spend a lot of time sitting? Maybe you work at an office where most of your time is at your desk, or maybe when you’re at home, you prefer to rest on the couch instead of being on your feet. Many people live a mostly inactive lifestyle, but they might not realize that inactivity can be the reason why they experience increased joint pain.

Learn the reasons why inactivity can hurt your knees and what you can do to change it.

Weakens Your Knees

If you live a life or limited activity, your body adapts to that lack of motion. Essentially, when you aren’t using your legs muscles, ligaments, and joints for moderate levels of activity, you are losing them. Your knees become weaker as you require less of them.

One runner found that as she took time off running to rehabilitate an injury, she could not run after completing her recovery because of knee pain. She had to complete additional physical therapy because the rest had caused her to develop a condition called chondromalacia of the patella.

Essentially, her kneecap would not follow the proper range of motion because she had developed some weakness in the joint. It’s a common condition for people who are not active. Even something as simple as going up or down the stairs can make your knees ache.

If you spend your day sitting, you also experience pain in other areas that can also aggravate the knee. Your quadriceps become tight, which exert a pulling sensation on your knees.

You can help your knees feel better by focusing on flexibility. Stretch daily, and participate in joint-stabilizing exercises like yoga. Try to be more active during the day. Stand at your desk, or take time to walk around the office a few times. Use the stairs instead of the elevator.

Increases Your Risk of Arthritis Pain

If you start to experience joint pain as a result of arthritis, your first instinct is to rest more, because walking, running, biking, or other activities cause pain. However, resting when you have knee pain is often the worst solution.

Resting will cause the muscles that give the knee support to weaken. As a result, they become less able to bear your weight, which results in greater joint pain. Reduced strength in the knee joint also translates to reduced stability, which can increase your risk for accidents and make exercising even more difficult to do safely.

If you have arthritis or if you have a history of arthritis in your family, staying active is one way you can help to prevent it from getting worse. Ask a knee specialist for exercises that are safe and helpful for strengthening your knees without causing you too much pain during workouts.

Promotes Weight Gain

A sedentary lifestyle is often why people struggle to manage their weight. Gaining weight with age is common, and spending your days seated can make that problem worse. With every extra pound, the pressure on your knees increases by about four pounds. So, just 10 pounds of extra weight means 40 pounds of pressure on your knees.

All that stress naturally means that your knees start to hurt, and they can hurt even more when you try to be active again. Make sure you intentionally choose low impact exercise as first. Try a stationary bike or a brisk walk in supportive shoes to begin. Focus on losing weight through diet control.

After you lose some weight, you can increase your physical workouts if your doctor believes they will be safe. You might try incorporating some resistance training to really give your lower body some increased strength and stability, as long as you also spend time stretching and increasing your flexibility.

Increases Risk for Osteoporosis 

From the Daily Mail

Being a couch potato weakens your bones: Adults in their 60s face greater risk of fractures if they spend hours sitting down each day – but walking 10,000 steps each day helps

  • The study of 214 adults was published today in the Journal of Public Health
  • It is the first to show a link between a sedentary lifestyle and osteoporosis
  • Participants’ hips and spines were scanned to measure their bone density

A couch potato lifestyle leads to weaker bones in later life, particularly for men, researchers have found.

Experts discovered that men spent more time on average sitting still than women and therefore had weaker bones, particularly in their lower back.

But the new findings, conducted by academics from Durham and Newcastle universities, show that even just completing 10,000 steps a day can help to keep bones strong.

The study showed that people in their sixties who spent a lot of time sitting down had weaker bones which increased their risk of developing ‘fragility’ fractures.

It is well known that weight-bearing and muscle strengthening exercises are important for building bone strength and preventing osteoporosis.

The study, published in the Journal of Public Health, is the first to show that a sedentary lifestyle in men is associated with weaker bones and osteoporosis.

More than half a million fragility fractures – where a fracture occurs from a fall at standing height or less – happen each year in the UK. It is estimated that by 2025, that number will have gone up by 27 per cent.

Dr Karen Hind, of the Department of Sport and Exercise Sciences at Durham University, said: ‘We know that excessive sedentary time can lower someone’s metabolism which can lead to being overweight and Type 2 diabetes.

‘What we now know is that being inactive is also associated with lower bone strength and an increased risk of osteoporosis.

‘Osteoporosis is a disease that affects older people but by encouraging this age group to keep active, it will help improve their bone health.’

The research team followed 214 men and women, aged 62, from Newcastle University’s Thousand Families Study.

Each participant wore a monitor for seven consecutive days which measured their physical activity and sedentary time. The number of daily steps was also recorded, and then compared with public health recommendations.

The participants’ hips and spines were scanned to measure their bone density.

Participants involved in 150 minutes of light physical activity a week had better bone strength than the more sedentary participants, according to the findings.

The men who spent more than 84 minutes per day sitting still, compared to the average of 52 minutes, had 22 per cent lower bone density in their spine.

The researchers say the impact on their bone density is similar to that of smoking, which is also a risk factor for osteoporosis.

The economic and personal costs of osteoporosis are substantial – in the UK the direct costs of fragility fractures are estimated to be £4.4billion which includes £1.1billion for social care.

The participants all lived in Newcastle-upon-Tyne, and Public Health England statistics indicate that the North East has the greatest proportion of physically inactive adults and the highest incidence of hip fractures compared to the rest of the UK.

The researchers said that the message from their findings is: stay active and reduce sedentary time.

They emphasised that the study shows that hitting the daily target of 10,000 steps and avoiding long periods of sedentary time will increase bone strength.

They say that even making daily lifestyle ‘hacks’ can make a difference – such as parking the car further away from the shopping centre or taking the stairs instead of the lift.

Dr Hind added: ‘Currently there are no specific guidelines for this age group to encourage light physical activity or to reduce sedentary time.

‘Yet, as people retire they are more likely to increase the time they spend watching television and reduce their daily step count.

‘It would be great to see initiatives that specifically target this group to increase their awareness of the importance of staying active and reducing the amount of time spent sitting still.’

Learn more about bone health


New Mexico Orthopaedics is a multi-disciplinary orthopaedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.

New Mexico Orthopaedics offers a full spectrum of services related to orthopaedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.

Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopaedic condition, and offer related support services, such as physical therapy, WorkLink and much more.

If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300.

Chronic Pain, Osteoporosis, and Bone Density Testing

Chronic Pain, Osteoporosis, and Bone Density Testing

Written by E. Michael Lewiecki, MD, FACP | Article Featured on PPP

Osteoporosis is a disease manifested by low bone density and poor quality of bone, resulting in skeletal fragility and increased risk of fracture.1 While osteoporosis is generally a silent and asymptomatic disease until a fracture occurs, pain and osteoporosis are often associated. Fractures usually cause sudden and severe pain, with non-union fractures and some vertebral fractures resulting in chronic pain. Recent evidence suggests that pressure-induced tibial pain may be an indicator of low bone density in patients without fracture.2 Some metabolic disorders that cause low bone density, such as vitamin D deficiency and osteomalacia, can cause bone and muscle pain,3 proximal muscle weakness, and postural instability4 in the absence of fracture. Chronic pain is associated with many risk factors for osteoporosis and fragility fractures. These risk factors may be categorized according to whether they are due to the underlying disease, the pain itself, or the treatment for pain (see Table 1).

Risk Factors

Diseases associated with chronic pain and osteoporosis include prevalent vertebral fracture, rheumatoid arthritis, inflammatory bowel disease, multiple myeloma, and insulin-dependent diabetes5 with diabetic neuropathy. Regional bone loss may occur with painful disorders such as reflex sympathetic dystrophy6 (Sudeck’s atrophy, algodystrophy) or immobilization of a limb due to trauma — with or without fracture.7

Chronic pain and its associated diseases may result in poor nutrition, impaired cognition, elevated serum cortisol8 or high levels of inflammatory cytokines,9 with potential adverse effects on bone density.

Some treatments for chronic pain disorders, such as glucocorticoids10 and anticonvulsants,11 may be harmful to bone. Other medical treatments, such as narcotics and antidepressants, may impair balance and mobility, resulting in increased risk of falls and fractures.12 Hypogonadism, another risk factor for osteoporosis, has been reported in men13 and women14 treated with opioids.

The consequences of a fracture may include additional acute and chronic pain, limited ambulation, disability, loss of independence, increased risk of future fractures and death.15 Chronic pain patients at risk for osteoporosis should be considered for bone density testing so that appropriate therapeutic intervention may be started to prevent fractures and their clinical consequences.

“…dual-energy X-ray absorptiometry (DXA) of the spine and hip is the recommended method for diagnosing osteoporosis and monitoring the effects of therapy.”

 

Bone Density Testing

Bone density testing is a non-invasive technique used to diagnose osteoporosis or low bone density, predict the risk of fracture, and monitor the effectiveness of therapy for osteoporosis. While measurement of bone density at peripheral skeletal sites with a variety of technologies is useful to increase osteoporosis awareness and predict fracture risk, dual-energy X-ray absorptiometry (DXA) of the spine and hip is the recommended method for diagnosing osteoporosis and monitoring the effects of therapy. The key to effective clinical management is the identification of high risk patients before the first fracture occurs, so that therapy can be initiated to reduce the risk of fracture.

Dual-energy X-ray Absorptiometry

DXA is used to measure bone mineral density (BMD) at the spine and proximal femur. With appropriate software, many DXA instruments can also measure BMD at the forearm and total body. DXA measures areal BMD (aBMD in g/cm2) by using ionizing radiation with photon beams of two different energy levels. DXA is the “gold-standard” method for the diagnosis of osteoporosis and monitoring the effects of therapy for the following reasons:

  • biomechanical studies have shown a correlation between mechanical strength and BMD measured by DXA,16
  • epidemiological studies have established a strong relationship between fracture risk and BMD measured by DXA,17
  • the World Health Organization (WHO) classification of BMD for the diagnosis of osteoporosis and osteopenia is based on reference data obtained by DXA,18
  • randomized clinical trials showing a benefit with pharmacologic intervention have selected subjects based on low BMD measured by DXA,19
  • there is a relationship between reduction in fracture risk with pharmacologic therapy and BMD increase as measured by DXA,20
  • the accuracy and precision of DXA is excellent.21

DXA is widely available in the United States, with an estimated 10,000 instruments in operation. Radiation exposure from DXA is extremely small,22 typically about the same as the normal daily level of background radiation. Conventional radiography, on the other hand, is an insensitive and subjective technique for evaluating bone density at any skeletal site, requiring 30-40% bone loss before a problem is detected. The best use of standard X-ray in the management of osteoporosis is to diagnose fractures, to monitor the healing of fractures, and to evaluate for some secondary causes of osteoporosis. If an X-ray is suggestive of low bone density, a quantitative measurement of BMD by DXA should be done.

When to Order a Bone Density Test

As with any clinical test, bone density measurement should only be done when the potential benefits outweigh the risks, and when the results are likely to play a role in making patient management decisions. The risks of bone density testing are extremely low. Pregnancy should be considered an absolute contraindication to doing any X-ray-based bone density test. Many organizations have developed guidelines to aid in the selection of those at risk for low BMD who most likely to benefit from knowledge of the results. The most comprehensive guidelines are those of the International Society for Clinical Densitometry23 upon the recommendation of an international panel of experts (see Table 2).

Osteoporosis/FractureRisk Factors
Due to Underlying Disease
Rheumatoid Arthritis
Insulin Dependent Diabetes Mellitus
Inflammatory Bowel Disease
Fragility Fracture
Reflex Sympathetic Dystrophy
Multiple Myeloma
Due to Effects of Pain
Elevated Cortisol
Poor Nutrition
Weight Loss
Poor Balance
Cognitive Impairment
Due to Pain Treatments
Narcotics
Antidepressants
Anticonvulsants
Immobilization

Diagnosis of Osteoporosis

A clinical diagnosis of osteoporosis may be made in a patient with a fragility fracture, provided other causes of fracture have been excluded. A fragility fracture is usually defined as a fracture resulting from a fall from the standing position. It is preferable, however, to identify patients at high risk for fracture before the first fracture occurs, just as risk factors for stroke and myocardial infarction should be identified and managed before a critical event occurs. The World Health Organization (WHO) classification of BMD uses the standard deviation (SD) difference between the patient’s BMD and the mean BMD of a young healthy population (Table 3). This is usually expressed as a T-score, which is calculated by subtracting the mean BMD of the reference population from the patient’s BMD and dividing by the SD of the reference population. A T-score of -2.5 or less is used for a densitometric diagnosis of osteoporosis in a postmenopausal woman.

“If a fracture has occurred, the goal of therapy is to stabilize the fracture, relieve pain, return the patient to pre-fracture levels of activity as soon as possible, and prevent future fractures.”

BMD and Fracture Risk

There is an exponential relationship between BMD and fracture risk, with fracture risk approximately doubling for every 1 SD decrease in BMD.24 Low bone density at any skeletal site is predictive of fractures at any skeletal site although, in general, site-specific fracture risk is best predicted by BMD measurement at that skeletal site. This principle does not hold true with spine BMD and spine fracture risk in the elderly, who often have degenerative arthritis in the spine that may result in an artifactual increase in spine BMD. There is no “fracture threshold.” Instead, there is a continuous relationship between BMD and fracture risk, so that fracture risk is never zero, regardless of how high the BMD, and it is never certain that a fracture will occur, regardless of how low the BMD. In clinical practice, patient management decisions must consider factors in addition to BMD that may affect fracture risk. The most important of these non-BMD risk factors are age25 and previous fracture.26 Fracture risk increases with age, even when BMD remains the same. Other clinical risk factors, such as family history of hip fracture, poor health, low body weight, and frailty, play a role as well. Since most hip fractures occur as a result of a fall, frailty and falling are potent predictors of hip fracture, independent of bone density. The risk of falling is affected by factors that include balance, mobility, strength, reaction time, visual impairment, medications, and cognitive impairment.

When to Repeat a Bone Density Test

A bone density test should be repeated when the expected amount of change in bone density equals or exceeds the Least Significant Change (LSC) — if knowledge of this change is likely to influence clinical management. The LSC is established for each technologist for each instrument used according to well-established guidelines,27 and is best expressed as an absolute value (g/cm2) with a 95% level of confidence. Values for precision error supplied by the manufacturer of the DXA instrument, which are automatically included on some computer printouts, are generally more optimistic than what is achievable in bone densitometry centers and should not be used. It is reasonable to repeat a DXA study 1-2 years after starting pharmacologic therapy to be sure that BMD is stable or increasing, and then repeat the study at intervals of 2 or more years to assure continuing response to therapy. In patients at risk for rapid bone loss, such as those being started on high dose glucocorticoid therapy, it is appropriate to repeat the DXA study every 6 months until stable. For elderly patients in whom a typical age-related bone loss of 0.5-1.0% per year is expected, it may take 3-6 years before a statistically significant change in BMD can be detected.

Indications for Bone Density Testing
  • Women aged 65 years and older.
  • Postmenopausal women under age 65 years with risk factors for osteoporosis.
  • Men aged 70 years and older.
  • Adults with fragility fracture.
  • Adults with a disease or condition associated with low bone mass or bone loss.
  • Adults taking medication associated with low bone mass or bone loss.
  • Anyone being considered for pharmacological osteoporosis therapy.
  • Anyone being treated for low bone mass to monitor treatment effect.
  • Anyone not receiving therapy in whom evidence of bone loss would lead to treatment.

Women discontinuing estrogen should be considered for bone density testing according to the indications listed above

Implications for Therapy

Non-pharmacologic therapy for patients at risk for osteoporosis and fragility fracture includes regular weight-bearing exercise as tolerated; good nutrition with adequate daily intake of protein, calcium, and vitamin D; balance training, fall prevention, and hip protectors for those with high risk of falling; and avoidance of bone toxic agents, such as cigarette smoking and excess alcohol. Pharmacologic therapy with FDA-approved agents can be expected to stabilize or increase BMD, and reduce the risk of fragility fractures by approximately 50%.28 If a fracture has occurred, the goal of therapy is to stabilize the fracture, relieve pain, return the patient to pre-fracture levels of activity as soon as possible, and prevent future fractures. Vertebroplasty and Kyphoplasty may offer pain relief for selected patients with vertebral fractures, although the indications for these procedures and the long-term benefits and risks are not well defined.29

World Health Organization Classification of Bone Mineral Density
Classification T-score
Normal -1.0 or greater
Osteopenia Between -1.0 and -2.5
Osteoporosis -2.5 or less
Severe Osteoporosis -2.5 or less with a fragility fracture

Conclusions

Patients with chronic pain may be at increased risk for osteoporosis and fragility fractures due to the underlying disease or disorder causing the pain, as well as factors associated with the pain itself and treatments given for the pain. BMD testing is an essential tool for the early diagnosis of osteoporosis or low bone density, allowing for identification of high risk patients and selection of appropriate therapy. Currently available therapy can reduce the risk of future fracture and its clinical consequences.


New Mexico Orthopaedics is a multi-disciplinary orthopaedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.

New Mexico Orthopaedics offers a full spectrum of services related to orthopaedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.

Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopaedic condition, and offer related support services, such as physical therapy, WorkLink and much more.

If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300.