Brittle bones

first_imgRelated posts:No related photos. Comments are closed. Brittle bonesOn 1 Jul 2001 in Personnel Today Like a silent stalker, osteoporosis can creep up unawares. The workplacepresents an ideal opportunity to catch this potentially crippling conditionbefore it strikes.  By Dr Alison Graham Osteoporosis, regrettably, is all too often a story of lost opportunities.It is not an understatement to say that the preventable is not being prevented,the diagnosable diagnosed, nor the treatable treated. It is not someone else’sproblem, we all have chances to prevent, diagnose and treat it if only werecognised them. Osteoporosis is not a new disease. It has, until recently,been dismissed as an inevitable consequence of ageing. It is not – and it isnever too late to treat it. Nor is it a disease confined to old ladies as mytwo patients in their thirties will testify. How important is osteoporosis? Osteoporosis affects one in three women and one in 12 men, and causes moredeaths than cancer of the ovary, uterus and cervix combined. It causes afracture every three minutes in the UK alone, and costs the NHS £1,500m peryear1. The hidden costs in terms of human suffering are incalculable – in arecent survey, women said they would rather die than suffer a hip fracture2.Fractures caused by osteoporosis are responsible for more days ofhospitalisation in women over 45 than any other disease3, and the outcome aftera fractured hip is poor. One in five patients dies, and half the survivorsnever regain their former level of independence. What has this got to do with the workplace? Occupational health is largely about prevention and recognition of therelationship between work and health and vice versa. The workplace provides avaluable opportunity to educate people about health matters. For example, themajority of wrist fractures occur in women in their 50s and 60s. They causedebility, pain, absence from work and often long-term functional difficulties.If the public and professionals were more aware of osteoporosis, many of itscomplications could be prevented. Once one fracture has occurred, we shouldheed the warning and try hard to prevent another. Osteoporosis can affect the workplace in other ways. Consider, for example,the impact on a working daughter when her elderly mother fractures her hip. Theworker affected may not necessarily be the patient for osteoporosis to have asocial and a financial cost. What causes osteoporosis? Osteoporosis literally means porous bone, and is caused by a reduction inbone mass and a micro-architectural deterioration in the bone structure. Thesetwo abnormalities result in a fragile skeleton and an increased risk offracture. Osteoporosis has been called the “silent thief”, becausethe patient often has no symptoms until a fracture occurs. Our 206 bones are not simply lifeless coat hangers on which we carry ourbodies. They are a living, responsive tissue, which continues to remodel itselfuntil the day we die. Old bone is taken away by cells called osteoclasts, andnew bone laid down by other cells called osteoblasts – a little like repairinga worn out motorway. In healthy bone, there is a balance between the twoprocesses. In osteoporosis, there is either too much bone removed, or too little beinglaid down. The bone that is present is normal, but there is not enough of it, and someof its supporting internal structures have been broken down. Consider acardboard box: if it is made of thick material and has internal supports likein a case of wine, it is strong, but if the card is thin and/or the internalsupports are removed, it becomes weak and can be crushed more easily. What increases the risk of developing osteoporosis? Bone is laid down during childhood and adolescence, with a peak bone massreached in the Thirties. After that, we lose bone gradually as we age. Womenachieve a lower peak bone mass than men, and lose it faster at the menopause,thus explaining their greater risk of fractures. The graph in Figure 1 can beused to explain to patients what happens to their bones and how they weakenover the years until they cross the theoretical threshold at which fracturesoccur. Bone mass is affected by many different factors Many diseases and lifestyle factors affect the peak bone mass (or the amountin our bone deposit account), and others affect the rate of loss. It isimportant to understand that the presence of risk factors does not mean thatosteoporosis or a fracture is inevitable. Likewise, healthy bones are notguaranteed just because risk factors are absent. The presence of risk factorsmerely highlights those people we need to look at more closely. Osteoporosis has been defined by the World Health Organisation in terms ofbone density and how it differs from the young adult mean. Bone density can bemeasured in a variety of ways and the gold standard method is DXA (dual X-rayabsorptiometry). Measurements can be taken at the hip, spine or wrist,depending on the device used. Most DXA machines are hospital based and not allpatients have access to a local service. Bone quality can also be assessed using ultrasound of the heel, known asQUS. This measures different features of bone to DXA and has been shown topredict fractures in post-menopausal4 and elderly women5. It does not diagnoseosteoporosis, it assesses fracture risk. Similarly, a cholesterol measurementcan predict the risk of heart disease but does not diagnose it. When asked,women wish to know what their risk of fracture is, as this is the clinicallyimportant outcome. However, the answer is not straightforward since many peoplewith osteoporosis will not fracture. What assessments are practical? Ultrasound is safe, painless, portable and quick and can be taken to thepatient. It is therefore ideal to be used in the community setting. It is vitalthat the technology is used appropriately and unfortunately heel scanning isnot suitable for pre-menopausal women or for men. This is because a lack ofdata in these groups makes interpretation of the results in terms of fracturerisk impossible. It is also essential that the heel scan is not judged in isolation. It is apiece in the jigsaw puzzle that we build for each individual. It is veryimportant to assess other risk factors that may have already caused bone lossor that may cause problems in the future and the result needs to be interpretedby a trained professional. Similarly with cholesterol, the result should beinterpreted in the context of the whole patient. What can be done? It is never too late to take action, but clearly the choice of actionchanges with age. The key message is that if a woman establishes her risk, shecan then take action to reduce the rate of bone loss, and thus prolong the timebefore she becomes vulnerable to fracture. Many interventions lie within the control of the individual and do notnecessarily need prescribed medication. A lifestyle that is good for bones isgood for hearts as well. There is no such thing as bad news with a riskassessment as the advance warning it provides allows intervention beforedisaster strikes and it has been shown that compliance with treatment is betterin women who have a test result to motivate them6. The issue of bone health could be raised in the workplace by displaying aposter asking about risk factors such as those in the box. This could helpidentify women at increased risk. Occupational health nurses should be vigilant, for these high-risk groupswill be present in most workplaces and there are ample opportunities to educateabout the benefits of hormone replacement therapy, exercise, not smoking andeating healthily. As long as we are all suspicious about osteoporosis, know how to recogniseit when it is already established and know how to identify those at high riskof developing it in later life, we will contribute to the enormous task thatfaces us. Preventing 200,000 fractures a year in the UK is a task that will notbe achieved by GPs and their prescribing budgets alone. The opportunitiespresented in the workplace mean that it too must play its part. Dr Alison Graham, MBBS, MRCGP, D.Occ.Med. is medical director of ScancareServices References 1. Torgerson DJ et al. (1999) The economics of fracture prevention inprimary care. UK Key Advance Series: Key advances in the effective managementof osteoporosis. In Press. 2. Salkeld G et al. (2000) Quality of life related to fear of falling andhip fracture in older women: a time trade off study.  British Medical Journal,320:341-346. 3. Kanis JA et al. (1997) Osteoporosis International,7:390-406. 4. Stewart A, Torgerson DJ, Reid DM (1996) Prediction of fractures inperimenopausal women: A comparison of dual energy X-ray absorptiometry (DXA)and broadband ultrasound attenuation (BUA). Annals of Rheumatic Disease, 55:140-142. 5. Bauer DC, Gluer CC, Cauley JA, et al. (1997) Broadband ultrasoundattenuation predicts fractures strongly and independently of densitometry inolder women. A prospective study. Archives of Internal Medicine; 629-634. 6. Bone and Tooth Society and National Osteoporosis Society (2000) Howfragile is her future? A report investigating the current attitudes towards andmanagement of osteoporosis in the UK. Risk factors Have you had any of the following:– An early menopause?– A previous fracture after a minor trip or fall?– Height loss of more than two inches?– A mother who has broken her hip?– Steroid tablets for more than six months?Ultraso und checklist– Ultrasound can be used toinvestigate the full range of risk factors– It must be carried out by trained personnel (preferablynurses)– There must be an auditable set of procedures that are managedby a trained and qualified physician– Practitioners should keep up to date in the subject area, andbe capable of changing as evidence emerges– The best equipment available should be used and operated tostrict quality control standards Previous Article Next Articlelast_img

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