Move It Or Lose It

Sunday December 6, 2009

Move It Or Lose It

Hey, lazy bones, get up and work out!

THE first thing that comes to mind when you talk about bone is calcium. But the journey to good bone health does not stop at getting the right nutrients. Getting the right exercise is also important for strengthening bones.

Don’t think that our bones are rigid. In fact, they’re not only strong, but also flexible. That’s how gymnasts are able to bend their bodies to seemingly impossible shapes without breaking their bones!

Bones are not only strong, they’re flexible too. With the right exercise and training, maybe you can bend your bones to unbelievable angles too! – Reuters

Because bone is living tissue, it is constantly reacting to the stress human activities put on it. With the right exercise and training, you can bend your bones to unbelievable angles too.

A bone consists of a combination of collagen and mineral crystals comprising calcium and phosphate. This collagen matrix allows bone to expand and contract without breaking. In other words, your bones will respond and become stronger to resist the force that regular exercise puts on it. Similarly, if you are physically inactive, your bones get weaker and more frail, exposing them to greater risk of fracture.

It’s a weight thing

Any exercise that requires you to carry your weight and go against gravity can help you improve or maintain bone mass. The strain of carrying your weight and the push and pull of your muscles will stimulate bone formation, thus making it stronger.

High-impact, weight-bearing exercises are the most effective for building strong bones, but do them only if you don’t have low bone mass or osteoporosis.

Exercise is meant to build bone, not break it. Activities like running, jumping, hiking, and dancing, and playing sports like tennis and badminton constitute high-impact weight-bearing exercises.

On the other hand, low-impact weight-bearing exercises like walking and low-impact aerobics are more suitable for those who want to build strong bones but cannot do high-impact exercises. You can also do resistance training and strengthening exercises like lifting weights or doing push-ups.

Be safe, however, by consulting your doctor or personal trainer first to avoid hurting yourself.

For the elderly, fall-related fractures can be debilitating. Up to 20% of those suffering from a hip fracture die within a year while two thirds of those who survive are disabled. Precautionary measures need to be taken to prevent this from happening.

Besides making sure that your house and surroundings are free from fall risks, you must also take steps to improve your balance and posture through exercise. Doing tai chi or yoga can give you better balance, posture, and coordination, which in turn can help prevent falls.

Everybody can do it

Exercise for healthy bone can be tailored to suit every life stage and need. Exercise can help build healthy bone during childhood and maintain bone health during adulthood. Older people who exercise regularly can strengthen their bones and reduce their risk of fracture.

So no matter what age you are, or what physical condition you are in, you can find an exercise that benefits you.

Although non-weight-bearing exercises can have cardiovascular benefits and are good for building muscles, they are not necessarily as effective as weight bearing ones. So if we’re talking about good bone health, then any activity that places a load on your bones is the way to go.

It is, however, dangerous to exercise without knowing your limits. Too much exercise can cause stress fractures and joint damage. Some exercises may even cause falls and so increase your risk of fractures. Those with osteoporosis and the elderly can put themselves at greater risk of fractures if they start off a rigorous exercise regime without consulting a doctor or physician.

Every exercise should be tailored to suit your needs and abilities. Approximately 30 minutes of exercise on most days of the week is generally recommended, but if you have low bone mass, are over the age of 50, or osteoporotic, you should seek professional advice before starting an exercise routine.

Be wary of common exercise pitfalls like laziness or time constraints. Exercise can be incorporated in your daily lives to suit your needs and lifestyle so it doesn’t have to be a chore. Be creative and make sure you enjoy doing it. That way, you will be more likely to continue doing it instead of putting in a half-hearted effort.

Building healthy bone is a life-long commitment and physical activity can go a long way in helping you achieve it. Whether you’re at home, work, or school, you can incorporate exercise to suit your lifestyles. In the end, what matters is that you get moving and that you enjoy the benefits for life.

Working out

There are many ways to incoroprate exercise into daily life. Here are some suggestions:

At work

* Use the stairs instead of the lift.

* Walk more by going to the restroom on the floor above you and take the stairs.

* Park a little further from your office so you can walk more.

* Go offline and deliver documents to colleagues by hand instead of by email.

* Walk instead of driving when going out for lunch.

At home

* Use the stairs instead of the lift if you live in an apartment complex.

* Carry your laundry basket up and down the stairs.

* March in place whenever you’re stuck with doing chores such as washing the dishes or doing the laundry.

* Do some jumping jacks while watching television.

* Turn on some music and dance!

* Walk up and down the stairs as a form of exercise.

At school

* Use the restroom on a different level, or at the other end of your building.

* Earn brownie points while building strong bones by helping your teachers carry their things.

* Walk around school instead of sitting around while waiting for the first bell to ring.

This article was contributed by the Osteoporosis Awareness Society of Kuala Lumpur as part of its Healthy Bone For Life programme and supported by educational grants from Fonterra Brands (Malaysia) Sdn Bhd and Rottapharm Madaus.

Bone Apetit!

Bone Apetit!

Sunday November 22, 2009

FOOD is a gastronomic treat for many of us, but more importantly, food is the fuel for life. However, many don’t know that our bones are alive, and it needs food to keep living too.

While we walk, skip and run, our bone is also actively breaking down and rebuilding itself. So just as we need food to keep going, bone also needs to refuel itself with the necessary nutrients. And calcium and vitamin D are equivalent to a gourmet spread for bones.

“Calcium is not only important for bone formation but is also used for bodily functions like maintenance of nerves and muscles. The body takes calcium from bone when it runs low, so we need to constantly replenish our calcium supply in order to avoid this,” says Dr Winnie Chee, a dietitian and honourary secretary of Osteoporosis Awareness Society of Kuala Lumpur.

According to Dr Chee, calcium consumption should be in accordance with your daily recommended intake. Different age groups have different needs for calcium. How to know how much you need per day? These are the recommended nutrient intakes for calcium:

·infant 0-6 months – 300mg (breastfed); 400mg (not breastfed)

·infant six-12 months – 400mg

·children one to three years – 500mg

·children four to six years – 600mg

·children seven to nine years – 700mg

·adolescent 10-18 years – 1000mg

·men 19-65 years – 800mg

·men >65 years – 1000mg

·women 19-50 years – 800mg

·women >50 years – 1000mg

·pregnancy – 1000mg

·lactating – 1000mg

Source: National Coordinating Committee on Food and Nutrition, Ministry of Health, Malaysia

For adults, you need around 800mg to 1000mg of calcium daily. It sounds daunting, right? But drinking one glass of milk (240ml) every morning is already contributing about 250mg to 500mg of your daily calcium intake. And milk is not the only source of calcium out there.

The Osteoporosis Awareness Society of Kuala Lumpur has released the Healthy Bone For Life Family Guidebook. The book covers information about bones, nutrition and exercise tips, fall prevention, and also osteoporosis treatment.

“You can also find calcium in foods like green, leafy vegetables like kai lan and Chinese pak choy, soy-based products like tofu and taufu fah, and also edible, soft-boned fish like canned sardine and anchovies,” says Dr Chee.

Dr Chee adds, “There are also non-dairy, calcium-fortified foods you can find in the market today. Many orange juice beverages, malted drinks, and yoghurt drinks, not to mention breakfast cereals, biscuits, and breads are fortified with calcium nowadays. So you are definitely spoilt for choice when it comes to choosing your calcium-rich foods.”

But where does vitamin D come in?

“Vitamin D helps your bone absorb more calcium,” Dr Chee explains. “Your body produces vitamin D when exposed to sunlight. However, the ability to synthesise vitamin D in the skin decreases with age, limited exposure to the sun, and the use of sunscreens. Therefore, spending a few minutes under direct sunlight every day is advisable to enable vitamin D production.”

But remember, it’s not just about calcium and vitamin D. Other nutrients also contribute to good bone health. Besides, eating just one type of dish is boring anyway, right? So whet your appetite with delicious and well-balanced meals every day by referring to the food guide pyramid.

“Grains should form the base of your diet. Include sources such as rice, bread and cereals and go for calcium-fortified ones which are good for bones. Then work your way up the pyramid by eating five servings of fruits and vegetables, which are beneficial for our bones,” advises Dr Chee.

“Bone is always breaking down and rebuilding itself in a process called bone remodeling. But as we go past the age of 50, bone breakdown, or resorption, happens faster than bone formation. Studies have shown that individuals who eat a lot of fruits and vegetables in their diet have slower rate of bone loss and less osteoporotic fractures.

“Next on the pyramid menu is protein-rich foods like meat, fish, poultry and legumes. Two to three servings a day is enough for your daily needs. And of course, complement your healthy meals with one to two servings of dairy products like milk and cheese everyday for a calcium boost. Finally, try keeping sugar, salt, fat and oil to a bare minimum,” Dr Chee explains.

Dr Chee also advises against over-consumption of salt and caffeine. According to her, high intakes of salt and caffeine can increase loss of calcium in the urine, and this will have to be replaced by drawing out calcium from its “savings” – your bones!

The most important thing to remember is to avoid overindulgence. Like everything in life, practice moderation so that you get enough to meet your needs without risking unnecessary side effects.

Weight issues also play a part in caring for your bones. Maintain a healthy body weight status because malnutrition can affect not only your health but your bones as well. Stay away from unhealthy eating disorders like anorexia, bulimia and binge eating. It’s unhealthy and it takes away all the pleasures of eating good food from you.

Who knows that taking care of your bones is so enjoyable, right? You feed yourself tasty, nutritious food and you can care for your bones at the same time! And it all begins with the awareness that your bones need feeding, just like any other living thing.

In conjunction with World Osteoporosis Day Carnival, OASKL has released the Healthy Bone For Life Family Guidebook with the tagline “Osteoporosis prevention begins today”. The book covers information about bones, nutrition and exercise tips, fall prevention, and also osteoporosis treatment. This book will be given free to the public when you make a donation of RM10 or more to OASKL. Cheques are to be made payable to Osteoporosis Awareness Society of Kuala Lumpur. To place your order, please contact Tel: (03) 5630 0791 or (03) 5630 1668.

This article is contributed by the Osteoporosis Awareness Society of Kuala Lumpur as part of its Healthy Bone For Life programme. It is supported by educational grants from Fonterra Brands (Malaysia) Sdn Bhd and Rottapharm Madaus.


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Making No Bones About Age And Health

Saturday May 9, 2009

PETALING JAYA: One in two Malaysian women above 50 are susceptible to bone problems, says Health Minister Datuk Seri Liow Tiong Lai.

Men of that age are not far better off either, with one in five prone to it.

Liow said this in his speech read out by the ministry’s secretary-general Datuk Seri Dr Mohd Nasir Mohd Ashraf at the “Listen To Your Bones” campaign organised by Fonterra Brands at Sunway Pyramid here yesterday.

“Studies also indicate that one in three women and one in five men over the age of 50 years may suffer from osteoporotic fractures. Of greatest concern is hip fracture, which causes the highest morbidity and mortality,” said Liow.

“Osteoporosis is a silent disease. Most people don’t realise that they have weakened bones until the bones break.”

Dr Mohd Nasir and Fonterra Brands general manager John McKay jointly launched the campaign to promote awareness on the importance of bone health.

The company’s nutrition manager Koo Pei Fern said women were more prone to bone problems because their smaller skeletal frames stored less calcium compared with men.

“But women with larger frames are less susceptible to osteoporosis because their bone structure acts as a calcium bank, allowing them to have stronger bones,” she said.

Koo added that women also stored less calcium when they experienced menopause as the reduced level of oestrogen hormones would lessen the absorption rate.

She pointed out that Malaysians also did not consume enough calcium due to the general lack of the mineral in the typical local diet.

“Teh tarik, for example, contains condensed milk which has very little calcium. Moreover, tea has caffeine, which reduces calcium absorption,” Koo said, adding that a person needed to drink two glasses of milk daily to meet the required calcium needs.

“Exercising regularly also strengthens the bones, especially activities which require people to carry their own weight such as climbing up stairs and walking. Swimming is not as effective because our weight is supported by the water.”

These Old Bones

Celebrate World Osteoporosis Day 2009 by sparing a thought for your bones.

HAVE you thought about your bones today? You should, because you need healthy and strong bones in order to do all the activities you enjoy doing everyday.

Now, imagine if you were to fracture or break a bone. It wouldn’t be fun, would it, to be restrained from doing activities you like? But imagine if that were to happen in your 60s or 70s. Would you want to suffer the pain and agony of fractures at that age?

According to Dr Lee Joon Kiong, president of the Osteoporosis Awareness Society of Kuala Lumpur (OASKL), a lot of people take their bones for granted until they break, or if they’re diagnosed with osteoporosis.

He says: “Osteoporosis is a disease where you lose bone mass, increasing your risk of fracture, usually in the hip, spine, or forearm. But, by the time the fracture occurs, it would be too late. You need to start taking care of your bones today to avoid complications like osteoporosis tomorrow.”

Osteoporosis is a disease that causes you to lose bone mass, increasing your risk of fracture, usually in the hip, spine, or forearm. In Malaysia alone, over one million people are estimated to be at risk of osteoporosis.

Dr Lee stresses that preventing osteoporosis has to start early, from childhood, in fact. “This is why we in OASKL have decided to mount our Healthy Bone For Life programme. It was launched in conjunction with our World Osteoporosis Day Carnival, which will be held at the Orange Concourse of Sunway Pyramid Shopping Mall until today, October 25, 2009,” he remarks.

Amazing bones

Dr Lee believes that the first step to good bone care is understanding. We are born with about 300 bones, which are mostly made of cartilage. As we grow up, the cartilage grows and is replaced with hard bones, which fuse together to form the 206 bones that adults have.”

Bone is a very important organ. It allows us to move and also provides structural support. Without it, we’ll become one mess of skin and organs.

Our bones also provide protection for our organs, in addition to an environment for blood cell production and storage of minerals such as calcium and protein.

Dr Lee says that while bone may look solid from the outside, it is actually made of a honeycomb of strands inside. In fact, if you were to cut a bone across, you would see it’s spongy inside, protected by the harder outer layer.

The outer layer is called the cortical bone, composed of compact bone tissue, while the interior is called the trabecular bone, which is a porous network of cells also referred to as cancellous bone. However, despite being less dense than the cortical bone, the cancellous bone is very strong and is able to withstand the strain human activity puts on it.

Bone consists of an organic component called collagen, with protein scattered in and around the collagen fibres, and also an inorganic mineral composition in the shape of crystals, where calcium and phosphate are deposited into. The combination of the collagen and mineral crystals is what gives bone its tensile strength.

Bones can become brittle

However, Dr Lee adds, bone strength can be compromised as we age. “The way to overcome this is by achieving a bone mass as close to our peak bone mass as possible. Peak bone mass is generally reached before the age of 30, so if you are in your 20s, you had better get cracking now. Meet your daily recommended calcium intake and start doing weight bearing exercise to maximise bone mass,” he says.

It is estimated that one in four women and one in eight men over the age of 50 suffer from osteoporosis. What is worse is that one in every three women and one in every five men over 50 will have an osteoporosis-related fracture in their lifetimes. In Malaysia alone, over one million people are estimated to be at risk of osteoporosis.

Dr Lee says: “Women should especially watch out for this silent disease. They are relatively protected from osteoporosis because of the production of oestrogen, which stimulates healthy bone formation. But oestrogen production decreases after menopause and this will speed up bone loss, increasing the risk of osteoporosis.”

Unlike many diseases, osteoporosis is called the “silent crippler” because it does not become apparent until a break or a fracture. For older people who suffered from a hip fracture, 10 to 20% die within a year while two third of those who survived remain disabled for the rest of their lives.

Dr Lee emphasises that living with osteoporosis is not only a burden to the sufferers themselves, but also to family members and caregivers, whether mentally, physically or financially.

He adds: “Osteoporosis-related fractures carry high morbidity and mortality, in particular osteoporosis-related hip fractures. The quality of fracture healing in elderly with osteoporosis is not as good compared to young adult fractures. Rather, the objective of osteoporosis treatment is to reduce the risk of further fracture or break by improving bone mineral density as well as bone quality. Treatment may include calcium and vitamin D supplements in combination with various pharmacological agents.

“However, you must also make the necessary changes in your diet and lifestyle so as not to be overly-dependent on medicine. Make sure you get enough calcium and vitamin D to meet your daily recommended intake. And if you are able to, try to get your body moving to stimulate bone formation.”

Weight bearing exercises are the most effective exercise in building bones. They include walking, jogging, stairs climbing, and tai chi. But be sure to consult your doctor first before you go for that trek around the park. Your doctor can recommend the most suitable type of exercise so that you don’t hurt yourself in the process.

Other factors you can control are to avoid excessive alcohol and caffeine consumption, and also excessive smoking. These three things can accelerate bone loss, increasing your risk of further fractures.

Find out your osteoporosis risk

Come to the World Osteoporosis Day Carnival that’s being held today (October 25) at the Orange Concourse of Sunway Pyramid Shopping Mall in Petaling Jaya.

The main attraction will be the Healthy Bone For Life Public Advisory Service, which includes osteopororis risk assessment, bone scanning, and dietary and lifestyle advice by healthcare professionals. It will be a good way for people over the age of 40 to know their risk levels and be motivated to seek early diagnosis and treatment.

Other attractions include fun, family activities like aerobics and dance demonstrations, games, and competitions. All the activities at the carnival are free.

> This article is contributed by Osteoporosis Awareness Society of Kuala Lumpur (OASKL) as part of its ‘Healthy Bone for Life’ programme. For further information, please contact Tel: (03) 5630 0791 or 5630 1668.

Drugs For Osteoporosis

Drugs for osteoporosis

The Doctor Says

By MILTON LUM

Various drugs are used to treat and manage osteoporosis.

BISPHOSPHONATES reduce the activity of cells that cause bone loss with little or no effect on cells that build up bone. They are effective in preventing and treating osteoporosis. They are taken on an empty stomach with plain water only daily or once a week. One should not take mineral water, coffee, tea, juice or dairy products before taking the tablet, which should be swallowed and not chewed or sucked.

If there is chest pain, heartburn, difficult or painful swallowing, one should stop taking the tablet and consult the doctor. Other side effects include abdominal discomfort, nausea, vomiting, diarrhoea, constipation, gas, headache and muscle, bone, or joint aches.

Bisphosphonates are not suitable for those who have problems in the oesophagus, kidneys that are not functioning well, low or high levels of blood calcium, cannot stay in an upright position for at least 30 minutes or are allergic to it.

•Risedronate is used to prevent and treat osteoporosis in women after menopause as well as women and men who are starting or continuing steroids for chronic medical conditions. It increases bone density and reduces the risk of spinal and non-spinal fractures. It helps preserve bone micro-architecture, provides sustained spinal fracture reduction over five years and reduces non-spinal fractures significantly over three years.

•Alendronate is used to prevent or treat osteoporosis in women after menopause, increase bone mass in men with osteoporosis and to treat women and men who are taking steroids. It increases bone density in both the spine and hip. There are reports that a combination of alendronate and oestrogen is more effective than either taken separately. Side effects are generally mild.

•Ibandronate is used to treat and prevent osteoporosis in women after menopause. It increases bone density in the spine and hip, and reduces the risk of spine fractures. It is available in a daily, monthly or three monthly dose. Side effects are generally mild.

•Etidronate is a bisphosphonate used to treat and prevent osteoporosis in women after menopause. It increases bone density at the lumbar spine and hip, and reduces the incidence risk of spine and hip fractures. The dose is daily for two weeks every three months. Continuous daily use will result in demineralisation.

Selective Oestrogen Receptor Modulators (SERMs)

These compounds bind to oestrogen receptors and bring about an oestrogen-like (agonist) effect in some tissues and an oestrogen-blocking (antagonist) effect in other tissues. There are two main types of oestrogen receptors. Each SERM binds the receptor in a unique configuration and depending on the tissue which the SERM binds to the receptor, it either blocks or activates its function. SERMs have no beneficial effect on menopausal symptoms while its effects on brain function are not yet known.

They are only prescribed after menopause and to those with few or no menopausal symptoms. It is unknown whether a combination of hormone and a SERM provides any advantage or loss of an individual effect, and their combined use is not recommended.

Raloxifene is a second generation SERM that mimics the oestrogen effects on bones but does not have oestrogen’s effects on the breast or uterus. It prevents bone loss, has beneficial effects on bone mass and reduces the risk of spine fractures. It is most suitable for osteopenic or osteoporotic women, who have breast or uterine problems, concerns about hormones or no major menopausal symptoms. It is taken once daily. It has a small increased risk of thromboembolism (VTE) similar to oral oestrogen. However, no cases of VTE have been reported in postmenopausal Asian women on raloxifene.

Calcitonin

This hormone is involved in calcium regulation and bone metabolism. It is taken as a single daily nasal spray or as an injection under the skin. In women who are at least five years postmenopausal, it slows bone loss and increases spinal bone density. Some patients also report pain relief from bone fractures. Injected calcitonin may cause an allergic reaction, flushing of the face and hands, nausea, increased urinary frequency and skin rash. The side effects are a runny nose and other signs of nasal irritation.

Strontium Ranelate

This compound has a novel action as it increases bone formation and at the same time reduces bone loss. It is used for treating postmenopausal osteoporosis and reduces the risk of spinal and non-spinal fractures. In addition, strontium ranelate has demonstrated reduction in fracture risk in a wide range of patients, from those with mild osteoporosis (osteopenia) to those above 80 years, regardless of severity of the condition. It is taken daily with a glass of water. The common side effects are nausea and diarrhoea.

Parathyroid hormone

Parathyroid hormone and its analogue teriparatide, which is a recombinant human parathyroid hormone, increases bone turnover, stimulating bone formation to a greater extent than bone loss. It increases bone density in the spine and hip and reduces the risk of spinal fractures significantly. It is used to treat individuals with severe osteoporosis especially after a fracture. Most doctors stop the bisphosphonates before starting teriparatide.

It is given as a subcutaneous injection daily. The common side effects include pain in a limb, anaemia, depression, vertigo, nausea, dizziness and muscle cramps. It cannot be given to those who have prior radiation to the skeleton, bone cancers and metabolic bone conditions other than osteoporosis.

Managing osteoporotic fractures

Surgery is used early in most instances today as conservative treatment results in myriad problems such as respiratory problems, thromboembolism, pressure ulcers, additional bone loss.

The majority of osteoporotic spinal fractures are stable. Operative treatment is carried out if there is spinal cord or nerve root compression. It may be used in chronic backache and progressive spinal deformities. Supportive braces may be used temporarily.

The relief of spinal pain can be problematic. Narcotic analgesics may be needed. Calcitonin is useful in providing pain relief. Physiotherapy and a brace can provide significant pain relief. Healing can be aided by adequate intakes of calcium, vitamin D and protein. Parathyroid hormone is prescribed in severe osteoporosis especially after a fracture.

Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.

Brittle Bones

The Doctor Says

By Dr MILTON LUM

Methods to diagnose low bone density are available. So don’t wait till you get a fracture to know that you are suffering from osteoporosis.

MOST people with osteoporosis have no symptoms initially because the loss of bone density is gradual. Some people never have symptoms. As the bone density continues to decrease, it leads to a fracture or gradually develops into a bony ache and deformities.

The fractures are usually at the ends of long bones and in the middle or lower spine. If several spinal bones fracture, an abnormal curvature of the spine (dowager’s hump) may result, causing muscle pain and deformity. There may also be loss of height. The long bones may fracture after a minor fall or strain. Hip fractures are a major cause of disability and independence in senior citizens. Wrist fractures are not uncommon in post-menopausal women. In addition, fractures take a longer time to heal in people who have osteoporosis.

It is not uncommon for osteoporosis to be diagnosed after a fracture has occurred. The doctor will take a history; carry out a physical examination and institute laboratory and imaging investigations. A diagnosis of primary osteoporosis is made after excluding secondary causes of bone loss.

Fractures take a longer time to heal in people who have osteoporosis.

When there is a low trauma fracture, the presumptive diagnosis is osteoporosis. The objectives of investigations are to confirm the diagnosis, assess fracture risk and to exclude secondary causes of osteoporosis.

The laboratory investigations are done to establish baselines or to exclude secondary causes of osteoporosis. They include a full blood count; serum calcium, phosphate, albumin, alkaline phosphatase; and renal function tests.

Other laboratory tests include hormone assays such as: thyroid function, sex hormones; serum protein electrophoresis; urinary proteins; bone marrow biopsy, if indicated.

Biochemical markers of bone turnover are not used in diagnosis but they are useful in monitoring treatment response.

A plain x-ray is not the best way to assess bone density. Osteoporosis is only apparent in a plain x-ray after more than 30% bone loss has occurred. However, x-rays may be taken of the affected area in patients with symptoms; in asymptomatic patients with a suspected vertebral fracture; height loss without other symptoms, or those who have pain in the spine.

Bone mineral density (BMD) provides an accurate measurement of bone mass. BMD measurements are usually considered in: women above 65 years and men above 70 years; presence of risk factors like oestrogen deficiency; prolonged absence of periods; family history of hip fracture, low body mass index, anorexia nervosa, prolonged immobilisation, hyperthyroidism, hyperparathyroidism, malabsorption and steroid therapy; x-ray evidence of osteopenia and/or spinal deformity; previous low trauma fractures of the hip, spine and/or wrist; height loss; and abnormal spinal curvature.

There are different methods of measuring bone density: dual energy x-ray absorptiometry, single energy x-ray absorptiometry, quantitative computed tomography and quantitative ultrasound.

The dual energy x-ray absorptiometry (DEXA) machine sends a thin beam of x-rays through the bones through two energy streams. There are two distinct energy peaks: one is absorbed mainly by soft tissue and the other by bone. The soft tissue amount is subtracted from the total with the remainder being a person’s BMD. All DEXA machines have software computing the data and displaying them on a monitor. The amount of radiation used is less than 10% of a routine chest x-ray.

The DEXA test, which is painless, takes about 10 to 30 minutes, depending on the equipment used and the parts of the body examined. There is usually focus on the spine and hip because these are the sites where most osteoporosis related fractures occur.

The DEXA results are in the form of two scores: the T score is the bone density expressed in standard deviations from the mean in healthy young adults of the same gender, while the Z score reflects the individual’s bone density compared to other people in the same age group of the same size and gender.

DEXA is currently the most accurate diagnostic method. It provides an accurate estimate of fracture risk. It cannot tell whether one will have a fracture but it will give the likelihood of getting a fracture. If the reading is low, one should not worry, but, instead set oneself a plan to improve the bone density.

Single energy x-ray absorptiometry (SXA) is used to measure the BMD of the radius bone in the forearm and the calcaneum in the foot. A single x-ray beam and a water bath to simulate a uniform soft tissue thickness are used to measure BMD. Its predictive value for spinal and hip fractures is less than that of DEXA. It is useful for identifying those who are at very low fracture risk and require no further assessment.

Quantitative computed tomography (QCT) is based on the differential absorption of ionising radiation by calcified tissue. It is an alternative technique used to measure the BMD of the spine, and can be used in adults and children. It is the only technique that can distinguish between cortical and cancellous bone. Its limited availability, relatively higher radiation dose, high cost and possible interference by osteophytes restrict its use.

Quantitative ultrasound (QUS) measures the speed of sound and broad band ultrasonic attenuation of an ultrasound beam passed in between two transducers. The role of QUS in diagnosis and treatment monitoring is currently not well defined, due to the diverse techniques, limited standardisation and comparable normal values. However, it is a low cost portable screening tool.

QUS may be used to predict future osteoporotic fractures in perimenopausal and immediate postmenopausal women, and senior citizens. Those with low QUS values for the ankle bone (calcaneum) are referred for BMD measurements of the spine.

When a person receives treatment for osteoporosis, the response is monitored by methods that include regular clinical assessments, DEXA of the spine every one to two years and two separate baseline measurements of biochemical markers e.g. osteocalcin, bone specific alkaline phosphatase and a repeat measurement two to three months after treatment was started, and yearly thereafter.

Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.

Taking A Fall

By ALLAN KOAY

The elderly do not just fall because of obstacles in their way.

IT IS commonly thought that when the elderly falls, it is caused by obstacles or hazards in their way, be they toys, pets, wires, cables or curtains. But studies have shown that there may be more to it than meets the eye.

There are other causes that may not be as apparent, such as problems with gait, balance and muscle function that come with age and affects those above 65.

Dr Erich Schacht: ‘Patients above 65 years of age have a reduction in neuromuscular coordination. In principal, they face a risk of falls.’

According to studies, about one-third of those aged above 65 experience one or more falls per year, and 90% of all non-vertebral fractures are from falls.

In the Rotterdamn Study, 20.7% of men and 44.1% of women with non-vertebral fractures had osteoporosis, and that suggests that low bone-mineral density may be less important in predicting non-vertebral fractures in the elderly. Rather, it is found that a combination of loss of bone strength and increased risk of falls that leads to osteoporosis-related fractures. Therefore preventing falls means preventing fractures.

“In the last decade, we were only talking about bones in osteoporosis – bone mass loss, bone strength loss, and bone quality loss,” said Dr Erich Schacht, an osteology and rheumatology expert from Switzerland who was recently in Kuala Lumpur to give a talk on the new drug alfacacidol that can help to prevent falls.

“In the elderly, there is another problem, which is that patients above 65 years of age have a reduction in neuro-muscular coordination – in muscle power or balance. In principal, they face a risk of falls.”

He concurred that more than 90% of hip fractures are caused by falls. Because the elderly have less muscle and fat, they have less protection at the hips. And because of neuro-muscular deficiency, they have slower or no reaction when they fall. And if they fall on an osteoporotic bone, the chance of the bone breaking is higher.

“There’s also a difference in the way young people fall and the way the elderly do,” said Dr Schacht. “The younger people more commonly fall to the front, and they have their arms in front of them to stop the fall. The elderly tend to fall sideways or backwards, and without reaction.

The loss of mobility, which increases with age, is a major threat to growing old successfully.

“The elderly have less possibility to react because of some changes in their bodies. Some types of muscle fibres which are responsible for fast reaction decrease in people with age.”

Dr Schacht said that while bone measurements are still very important in the field of osteoporosis, fall-risk assessment is also needed. There are different tests that can be carried out to determine if a person faces the risk of falling.

“Only when we have both (bone measurements and falls assessment), can we calculate an individual’s real risk of hip fracture,” he added.

“Just measuring the bone-mineral density is not enough. It has been shown in the last few years, from big studies, that more than 50% of hip fracture patients didn’t have osteoporosis. Why did they have hip fractures? Because not only the bone mass, but also the bone structure and quality are negatively changed.”

The tests to assess a person’s risk of falling include the lower extremity test where a person is asked to stand with feet close together for 10 seconds, then stand with the heel of one foot in line and touching the toe of the other foot. Those who cannot stand in this way for more than 10 seconds have a risk of falling.

Another is the timed up-and-go test. A person sits in a chair of normal height, gets up and walks 3m, and then walks back and sits down again. If she or he takes more than 12 seconds to do it, then there is a risk of falling.

Then there is the gait velocity test, where a person is required to walk normally for 4m, and if the she or he walks less than one metre per second, it shows a high risk of functional decline, which is related to falls and fractures.

But Dr Schacht said it is not all just about the bones, as bones and muscles are a unit. If you don’t use your muscles, you also lose your bones.

“You see it in hospitals with bed-ridden patients, or in space where astronauts lose muscle mass and then bone mass,” he explained.

Correction of vision and minimising the dosage of drugs combined with muscle, gait and balance training such as tai chi, can help to prevent falls.

“So the muscle is responsible for the bone’s growth. Therefore a drug that affects both muscle and bone can positively influence bone strength and reduce falls.”

Such a drug is already being introduced. Called alfacalcidol, the drug has been shown in tests to greatly reduce falls in a community of men and women with a total calcium intake of more than 500mg a day and normal vitamin D serum levels.

Alfacalcidol is a D-hormone analog that works simultaneously in the parathyroid hormone, immune system, intestine, bone muscle and nerves.

“Muscle growth, and muscle differentiation and maturation can be controlled by this drug,” said Dr Schacht.

He said alfacalcidol has been shown to influence the fall-risk assessment tests.

“Studies have shown that if you cannot do these tests within the stipulated time, in 10 years, you will have a 60% risk of getting a hip fracture,” said Dr Schacht. “But if a patient uses alfacalcidol, there is a reduction of two seconds in the performance of these tests.

Ultimately it is the loss of mobility, which increases with age, that is a major threat to growing old successfully. Mobility impairment is what leads to gait and balance problems, and coupled with vision and cognitive impairment, increases the risk of falls.

Correction of vision and minimising the dosage of drugs combined with muscle, gait and balance training such as tai chi, can help to prevent falls.

“The elderly don’t do sports like young people,” said Dr Schacht. “There is no specific rehabilitation programmes for muscles and bones. But the only thing I can recommend, which has been validated, is tai chi. And it’s not only working in Asia, it’s working for American housewives as well.”