Hughston

Health 6262 Veterans Parkway P.O. Box 9517 ColumbusAler GA 31908-9517 t VOLUME 11, NUMBER 4 www.hughston.com FALL, 1999

Osteoporosis Compression fractures in the Am I at Risk? osteoporotic lumbar spine (lower back)

Vertebral (bone) body  What is osteoporosis? Central expansion of the  Osteoporosis, or “thin” bones, is a intervertebral disk  disease that gradually weakens bones, making them more fragile and likely Vertebral body to break. It is not a form of arthritis. Osteoporosis leads to an increase in certain types of fractures (broken  bones), such as hip fractures, wrist Restricted fractures, and compression fractures intervertebral  of the spinal vertebrae (back bones)  foramen (space through (Figure). Although it can occur in men which nerves exit spine) or women at any age, this condition most commonly affects women after Normal intervertebral foramen menopause. Our bones are dynamic tissues; new  Spinous process bone is constantly growing to replace old bone. The rate of new bone Intervertebral disk Normal adjacent lumbar vertebrae and intervertebral disk growth changes as we age. Bones The Hughston Foundation, Inc. ©1999 grow quickly during childhood and (Cross-sectional views) adolescence and thicken during early bone mass while they are growing and Inside This Issue: adulthood. Between ages 25 and do not experience the accelerated  Screening Tests for 35, our bones reach their maximum phase of bone loss that women have Osteoporosis thickness, which is considered “peak in their early menopausal years. bone mass.” After early adulthood, Therefore, osteoporosis generally  Prevention and Treatment of bones begin to lose mass faster than occurs less frequently in men. Osteoporosis they can replace it. In women, the  Cardio Kickboxing rate of bone loss increases as estrogen Risk factors levels decrease after menopause. Left Several factors increase the risk of  Spinal Injuries in Adolescent unchecked, this bone loss can lead to developing osteoporosis. They include Athletes osteoporosis. hormonal status, heredity, lifestyle  General Exercise Guidelines Age-related bone loss in men choices, use of certain medications, from the American College of occurs almost as rapidly as in women. physical activity level, and associated Sports Medicine However, men develop a greater disease states.

Page 1 FOR A HEALTHIER LIFESTYLE In women, menopause, which strength of bone and rate of bone Screening Tests for can occur naturally or as a result of loss. For example, alcohol is toxic to surgery (removal of ovaries), is the bones. Heavy drinking (i.e., more Osteoporosis most common risk factor. The chance than two alcoholic drinks each of developing osteoporosis can be day) can cause osteoporosis even if Osteoporosis describes a decrease more problematic for women who you do not have other risk factors. in bone mass. It causes dense bones have an early menopause because Smoking reduces bone mass and can to become thin and porous. Having they prematurely lose estrogen. Men interfere with estrogen function. You thin bones increases your risk for with a low testosterone level are also are at increased risk of developing developing a fracture (broken bone). at risk for osteoporosis. osteoporosis if your diet has always Approximately 10 million people in You are at increased risk if you have been low in vitamin D and calcium, the United States have osteoporosis, older relatives who have sustained which are the substances that help the and 18 million more have early certain fractures (e.g., hip, wrist, and body build bone. When eaten in large thinning of bones that puts them spine), are hunched over, or have amounts, protein-rich or salty foods at increased risk of developing lost height because of osteoporosis. may cause your body to lose calcium. osteoporosis. However, only 23% of Women of all ethnic backgrounds are Caffeine and certain medications, people who have osteoporosis know at risk for developing osteoporosis; such as cortisone or excess thyroid that they have it or have talked with however, white and Asian women are hormone, increase calcium loss. their doctor about their condition. at a higher risk than other women are. (However, do not stop taking any Special bone density tests are Thin, petite, small-muscled women prescribed medication without your available to help your doctor find out are at higher risk than other women doctor’s approval.) Inactivity weakens if you have osteoporosis and to what are. bones. Over time, these weakened degree osteoporosis has affected your Beginning in your late teenage bones can become thinner and can bones. Using the information from years, lifestyle choices affect the break. the test, your doctor can prescribe Bone loss is associated a treatment plan to help strengthen with a variety of diseases and your bones. conditions, such as Paget disease, Who needs a bone density test? multiple myeloma, anorexia All women who are 65 years of age nervosa, diseases treated with or older should have a bone density steroids, and malabsorption of screening test. Women should have a calcium or vitamin D. Advanced screening test at an earlier age if they kidney and liver disease can have a family history of osteoporosis, contribute to an acceleration have an increased incidence of in osteoporosis. Osteoporosis fracture after the age of 45, currently is a characteristic of several are smoking, are underweight, or endocrine (glandular) diseases, have other risk factors discussed in such as overactivity of the “Osteoporosis: Am I at Risk?” (p. 1). thyroid or parathyroid glands, In addition, women or men who are excess production of growth considering therapy for osteoporosis hormone, Cushing syndrome, should be screened. If a person has and hyperprolactinemia. a disease or is taking any medication Osteoporosis can affect the that can cause bone loss, he or quality of your life. Talk with your she should have a screening test. doctor about the factors that may Women who have been on hormone put you at risk for this condition replacement therapy for a prolonged and about what you can do to time also need to be screened. prevent or treat it. For more information, contact the Types of screening tests National Osteoporosis Foundation, Clark H. Cobb, M.D. Several tests are available to screen 1232 22nd St, NW, Washington DC Columbus, Georgia bones for osteoporosis. The most 20037-1292, (202) 223-2226 (telephone), widely used and most accurate test or http://www.nof.org. The Hughston Foundation, Inc. ©1999 is called a DEXA (dual-energy x-ray absorptiometry) scan. The DEXA Page 2 FOR A HEALTHIER LIFESTYLE Prevention and Treat- ment of Osteoporosis

Osteoporosis is a common cause of fractures (broken bones), especially in women who are beyond menopause. However, by strengthening your bones, slowing bone loss, and avoiding falls, you can help prevent or treat the condition and avoid fractures.

Diet Prevention and treatment of The Hughston Foundation, Inc. ©1999 osteoporosis begin with proper diet. Ensuring that you get enough calcium scan can measure the bone density 7.5 mg or more of prednisone each and vitamin D each day is a great in your spine (back bone), hip, or day for more than three months. start (Table). Calcium helps your body whole body. It is painless and takes (Steroids are medications given to build bone, and vitamin D helps about 15 minutes to complete. Some treat various diseases, such as arthritis, your body absorb calcium. Calcium blood tests also are available, but they asthma, Crohn disease, and lupus.) can be found in dairy products (e.g., mainly are used to determine how 4. You have primary milk, cheese, yogurt, and ice cream); effective treatment is. hyperparathyroidism (overactive in salmon and sardines with bones; parathyroid). in dark green, leafy vegetables (e.g., What do the results mean? 5. You are being monitored to assess kale and broccoli); and in foods with The DEXA scan can give three how well your bones are responding added calcium (e.g., orange juice). basic results: 1) a normal scan, 2) to a United States Food and Drug For example, a one-cup serving osteopenia (early thinning of bones), Administration-approved osteoporosis of milk contains about 300 mg of or 3) osteoporosis. Your need for drug therapy, such as estrogen, calcium, and a one-cup serving of further evaluation and treatment is alendronate (Fosamax), or calcitonin. broccoli contains about 135 mg. based on the amount of bone loss In certain cases, Medicare will Supplements also provide needed that this scan shows. cover the cost of having a DEXA scan calcium. If you need to take a Will Medicare cover the cost? more often than every two years. supplement, choose it carefully. Avoid Currently, Medicare covers the cost Your doctor can tell you if Medicare bone meal and dolomite supplements of one DEXA scan every two years for considers you eligible for more because they may contain lead. specific diagnoses, which include the frequent testing. You need at least 400 IU of following: Osteoporosis can be a debilitating vitamin D each day. You can get 1. Your doctor or other qualified problem for women and men. By your daily requirement by taking medical professional determines using special tests, such as the DEXA a multivitamin; getting 30 to 60 that you are estrogen deficient scan, your doctor can diagnose the minutes of sun exposure (wear (i.e., postmenopausal) and at risk degree of bone loss and can formulate sunscreen and protective clothing); for developing osteoporosis based a treatment program to strengthen or consuming foods, such as fortified on your medical history and other your bones and help you remain milk (a one-cup serving contains 100 findings. active. IU) or salmon (a three-ounce serving 2. X-rays show abnormalities of your contains 425 IU). Although vitamin D vertebrae (spine bones) that indicate Kristyn Fagerberg, M.D. in adequate amounts helps your body osteoporosis, osteopenia, or fracture. Columbus, Georgia absorb calcium, it is harmful if taken 3. You are receiving or expecting to in excessive amounts. Most people receive steroid therapy consisting of should avoid taking more than 800 IU each day. Page 3 FOR A HEALTHIER LIFESTYLE of menopause. Unfortunately, The use of DEXA (dual-energy Table. some women cannot or will x-ray absorptiometry) scan bone Daily not take hormone replacement density tests has greatly increased the therapy because of side effects accuracy of diagnosis and has allowed Calcium Needs (e.g., breast tenderness, slight better monitoring of the disease and bloating, and vaginal bleeding), its treatment (see "Screening Tests for for Women certain risk factors (e.g., Osteoporosis," p. 2). Throughout Life endometrial, breast, or uterine In addition to checkups, you can cancer), or other associated help prevent osteoporosis by making Age Calcium problems (e.g., uncontrolled some lifestyle changes. Stop smoking needs hypertension, impaired and decrease your alcohol intake. liver function, or porphyria). Increase your physical activity level 11 to 24 years 1200 to 1500 mg Some women may not be and improve your diet. 25 to 50 years 1000 mg able to take estrogen therapy All women, and even some if they have problematic 51+ years 1500 mg men, should be concerned about diabetes, gallbladder disease, Pregnant or nursing 1200 to 1500 mg osteoporosis. For women, waiting migraines, pancreatitis, until your postmenopausal years Source: National Institutes of Health Osteoporosis high triglyceride levels, or to consider the risks and to make and Related Bone Diseases~National Resource endometriosis. However, lifestyle changes may not be prudent. Center (http://www.osteo.org/osteo.html). these women may be able to Education, wise lifestyle choices, and take other medications, such regular screenings can reduce the Exercise as alendronate (Fosamax), likelihood that this disease will affect You can help reduce the risk calcitonin, or calcium plus vitamin your quality of life. of developing osteoporosis by D. Talk with your doctor to find out exercising regularly. Your regular about the best choice for you. Clark H. Cobb, M.D. Columbus, Georgia exercise program should include Home safety weightbearing and resistance Falls often lead to fractures in exercises that strengthen bones and people with osteoporosis. To prevent muscles. Participate in this program falls, create a safe home. Remove or three to five times each week. anchor rugs and furniture that may Weightbearing exercises include cause you to trip. Install nightlights Cardio Kickboxing activities such as walking, dancing, and grip bars in your bathroom and hiking, and housework. Resistance use a rubber mat in the floor of your exercises include weight training and Cardio kickboxing -- a combination tub. Keep regularly used items at a of aerobics, boxing, and martial pushups. Remember to talk with your height you can reach easily without doctor before starting any exercise arts -- is one of the most popular a stool. Make sure that the rooms in fitness trends to hit gymnasiums in program. He or she can help you your home are well lit. create a program that fits your needs recent years. These workouts, which and abilities. Screenings and lifestyle changes are inspired by martial arts, have By age 30, you and your doctor motivated many people to start a Medication should discuss your risk of developing fitness program. Your doctor may prescribe various osteoporosis. Regular osteoporosis This intense, total-body workout medications that help slow the loss screenings that may include bone can improve strength, aerobic fitness, 1 of bone mass so your body can build density tests should begin for women flexibility, coordination, and balance. new bone as fast as old bone is lost. by age 65 and for men by age 75. The American Council on Exercise Hormone replacement therapy (i.e., Younger men and women should (ACE), which evaluates exercise replacement of estrogen) is one of the have these regular screenings if they products and programs, notes most valuable options for women who have alcoholism, use tobacco heavily, that, during a one-hour kickboxing are candidates for such medication. or have an associated disease (e.g., workout, you can burn from 500 to In addition to the treatment of bone hyperparathyroidism, disease treated 800 calories, which is up to twice the loss, the benefits of this therapy with steroids, glandular disease, or calories you burn during a one-hour include a reduction in the risk of advanced kidney or liver disease). step-aerobics class. heart disease and in the symptoms Kickboxing classes can be a great Page 4 FOR A HEALTHIER LIFESTYLE alternative for people who have to your body. Kick at a level that is you begin the 40- to 45-minute become bored with weight-room comfortable to you. Don’t do a move aerobic section, which includes kicks, cardiovascular activities, such as brisk that hurts, even if you are doing it punches, speed bag, shadow boxing, walking or jogging on a treadmill. correctly. Take breaks or stop if you jump rope drills, and footwork. They also provide an option for feel tired. Drink plenty of water These moves usually are done in people who enjoy the “semi-dance” throughout the class. combination formats (e.g., kick, knee, movements found in aerobics or step 5. Do not wear or hold weights jab, and jab). You do many repetitions classes. when punching or kicking. Although so that you can focus on proper body However, kickboxing-style fitness using weights can help develop your mechanics rather than on what move programs are not necessarily geared aerobic fitness in certain programs, or combination is coming up next. toward the beginner. The beginning the risk of joint injury outweighs the A cool-down period follows the cardio kickboxer must have above- benefits for the beginning kickboxer. aerobic workout. This period can average endurance, strength, and 6. Remember that this activity is not include strengthening and abdominal flexibility. ACE advises exercisers to a self-defense course. exercises. When your heart rate keep the following things in mind decreases, you stretch for five to 10 when participating in this aerobic Class format minutes. Most classes are between 60 activity1: At the beginning of each class, the and 90 minutes long. 1. Before beginning a class, ensure instructor teaches various moves Cardio kickboxing is meant to that the instructor is properly certified and their names and initiates a slow be a fun and effective program for to lead a safe and effective class. practice so you become familiar achieving your fitness goals. If you This certification should come from with the format. Next, you warm follow these guidelines, it can be just an accredited fitness organization, up for five minutes with some of that! such as ACE, American College of the moves you just learned. Once Sports Medicine, or Aerobic Fitness your muscles are warm, you stretch Helen Reinking, P.T.A. Association of America. them. Stretching focuses on the Columbus, Georgia 2. Talk with a qualified fitness major muscle groups, including the professional to find out whether hamstrings, adductors, heel cords, 1. Beginners should use care with Tae Bo and cardio kickboxing is an appropriate back flexors and extensors, and the other kickboxing workouts. Phys Sportsmed activity for you. You should already muscles of the shoulder and neck. 1999;27(6):28. be exercising aerobically at least three After warming up and stretching, times each week for 20 to 30 minutes and maintaining your target heart rate (see “General Exercise Guidelines from the ACSM,” p. 7). In addition, you should have good flexibility and coordination. If you have had orthopaedic surgery or other health problems, get permission from your doctor before beginning the class. 3. Work with a qualified instructor to learn and master proper technique. At the beginning of the class, the instructor should teach various techniques and should allow you to practice them. He or she can demonstrate how to kick and punch without overextending or locking your joints. The instructor can show you how to modify different moves so that they are comfortable for you and are executed safely and correctly. 4. Pay attention to what feels right The Hughston Foundation, Inc. ©1999 Page 5 FOR A HEALTHIER LIFESTYLE Spinal Injuries in Ado- Physes (growth plates) are areas on during sports participation. Ligaments the ends of a child’s bones where the and muscles that support the spine lescent Athletes bone grows. As the skeleton matures, may not grow as fast as bone, and, the physes harden, and bones stop therefore, they may become tight, Because of their age and growing. Girls reach skeletal maturity putting increased stress on the spine. involvement in vigorous activities at about 16½ years of age; boys, at Difficult maneuvers involving and sports, adolescents risk injury to about 17½ or 18. “flight” account for most spinal the spine (back bone). Certain types injuries. During these activities, the of sport activities increase the risk of Causes athlete is airborne and lands on a injury, especially to the lower back. Trauma and repetitive stress can hard surface, such as the floor in However, these athletes can take cause back injury in adolescent gymnastics, or the water, such as in steps to prevent many types of spinal athletes. Repetitive bending and diving maneuvers. Other activities injuries. twisting put athletes at risk for spinal associated with spinal injuries include injuries. During long training days, blocking in football, takedowns in Anatomy and skeletal development athletes are at increased risk of injury wrestling, and use of heavy weights The spine is made up of vertebrae because their fatigued bodies cannot and attempts at complex free-weight (bones), intervertebral disks (shock give full protection to the back. Using lifts in weight training. absorbers between vertebrae), and improper sport technique and having the spinal cord and other nerves weak abdominal and tight leg muscles Specific injuries (Figs. 1A and 1B). The vertebrae and also can lead to injury. Spondylolysis and spondylolisthesis. intervertebral disks protect the spinal The lumbar vertebrae (bones of the Putting repetitive stress on the cord, and they enable the torso to lower back) are more prone to injury vertebrae can cause a thin area of move in many directions. in the growing adolescent, especially bone, called the pars interarticularis, to fracture (break). Spondylolysis Fig. 1A Fig. 2A refers to a fracture on one side of the pars interarticularis (Fig. 2A). In

 spondylolisthesis, the fracture has Vertebral body occurred on both sides of this area and the fractured vertebra has slipped forward against its neighboring Intervertebral disk Fractured pars vertebra (Fig. 2B). Repetitive interarticularis hyperextension of the lower back, Vertebral body such as excessive back bends by Fig. 2B gymnasts or by football linebackers, can lead to these conditions. Disk herniation. Intervertebral

 disks are made up of firm, gristle-like Disk fibers that encompass a soft, fluid- Front view of normal lumbar like center. Disk material can bulge vertebrae (lower back bones) into the spinal canal and push on and intervertebral disk the spinal cord or another nerve. In adolescents, disk herniation most Fig. 1B commonly results from repetitive Vertebral  body trauma to the back. Spinal In adolescents, a vertebral growth plate and its adjacent disk can  cord become displaced into the spinal Sacral canal and push on the spinal cord. vertebrae (tail bones) This condition is called slipped Top view of vertebral apophysis. It usually normal lumbar Cross-sectional view  results from heavy lifting or from vertebra The Hughston Foundation, Inc. ©1999 participation in sports that require Page 6 FOR A HEALTHIER LIFESTYLE General Exercise Guidelines from the ACSM

The American College of Sports Medicine (ACSM) recently updated its position stand on the quantity and quality of exercise for healthy adults.1 For improvement of cardiovascular fitness and body composition, the ACSM recommends performing physical activity three to five times each week for 20 to 60 minutes at a time. The activity should involve the large muscle groups (e.g., walking, running, cycling, and swimming). The level of intensity (target heart rate) for this physical activity should be at least 55% to 65% of your maximum heart rate. (You can estimate your maximum heart rate by subtracting your age from 220.) You can quickly determine if your intensity is too high by taking the “talk test”; if you cannot maintain a conversation with your exercise partner while exercising, then your intensity is too high. The ACSM also recommends that you include muscular strength and flexibility training in your exercise program. If you are not currently exercising, please consult your physician before beginning any exercise program. Consistency is the key to success in any exercise program; choose an activity that you enjoy and are likely to continue throughout your adult life. For more information contact the ACSM (http://www.acsm.org). William C. Etchison, M.S., and David T. Curd, M.S. 1. American College of Sports Medicine Position Stand. The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness, and flexibility in healthy adults. Med Sci Sports Exerc 1998;30(6):975-991. very strenuous training, such as she needs to seek treatment from a particular activity. gymnastics. doctor. Parents should be aware that the Fractures. Blows to the back can problem can reoccur. If it does, cause fractures to certain parts of Treatment the adolescent will have to receive the vertebrae. Likewise, the physes To treat a back injury, the treatment again. and sacrum (tail bone) also can be adolescent athlete must stop playing fractured. Activities in which the the sport and participating in weight Prevention athlete can get hit in the back or can training, and he or she must see Adults can help adolescent athletes fall from a great height can lead to a doctor. The primary care doctor prevent spinal injury. For example, spinal fractures. examines the athlete's back and, if coaches can institute shorter practices. Scheuermann’s disease. This necessary, refers the adolescent to Properly trained coaches, athletic condition results in an exaggerated an orthopaedic doctor. The doctor trainers, parents, or other adults can curve (hump) of the upper back may prescribe a pain medication. supervise training sessions. They also involving at least two abnormally Some adolescents need to wear a can teach proper technique for weight wedge-shaped vertebrae. The cause is back brace as part of the treatment. training and various exercises. not known. A physical therapist instructs the Low back injury in adolescents athlete in appropriate conditioning, is a serious problem. However, if Symptoms stretching, and strengthening diagnosed and treated properly, the Pain often accompanies back exercises to rehabilitate the back athlete usually can return to vigorous injuries. In many cases, activity makes and to enable him or her to return to activities. the pain worse. To determine the sports participation. Lawrence D. Powell, M.D. seriousness of your adolescent’s back After treatment, the doctor Atlanta, Georgia problem, pay attention to whether he decides when the adolescent athlete or she has back pain at night, limited can return to sports participation. Galasko CSB. Back pain in children. In: Jayson MIV (editor). The Lumbar Spine and movement of the lower back, or Sometimes, the athlete has to Back Pain. 4th edition. Edinburgh: Churchill pain that goes down the leg. If your decrease the intensity of practice or Livingstone, 1992; 603-617. adolescent has these symptoms, he or change the way he or she performs a Page 7 FOR A HEALTHIER LIFESTYLE Editor Raloxifene: A New bone-building medications. Recently, George M. McCluskey III, M.D. researchers showed that raloxifene Managing Editor Medication to Fight helps build bone in the spine and Elizabeth T. Harbison hip and reduces the risk of vertebral Art Director Osteoporosis (spine bones) fractures.1 In addition, Carolyn M. Capers, M.S.M.I., C.M.I. Women now have another the medication is associated with Editorial Board medication to build bone and Thomas N. Bernard, Jr., M.D. a lower incidence of breast cancer Douglas T. Cannon, M.D. reduce the risk of fracture associated and has been shown to lower “bad” Clark H. Cobb, M.D. with osteoporosis. Raloxifene (ruh- cholesterol levels.1,2 Although, David T. Curd, M.S. LOCKS-uh-feen) hydrochloride, William C. Etchison, M.S. the medication does not relieve Bruce A. Getz, ATC a medication used to prevent menopausal symptoms, it provides Charles H. Keaton, FACHE, CEO osteoporosis, now can be used to an alternative for women who Teri LaSalle, M.S., P.T. treat the condition. Leland C. McCluskey, M.D. cannot or will not take estrogen, Jessie G. Wright, M.S., R.D., L.D. During menopause, dense bones alendronate, or calcitonin due to Jill Yates, R.N., O.N.C. lose mass faster than they can certain side effects, risk factors, or replace it. As they become thin and other problems. Suggested readings and classic porous, bones can fracture easily. references for articles contained 1. Ettinger B, Black DM, Mitlak BH, et To slow this process, doctors often in this issue can be found on www. prescribe medications, such as al. Reduction of vertebral fracture risk in postmenopausal women with osteoporosis hughston.com alendronate (Fosamax), estrogen, treated with raloxifene. JAMA 1999;282:637- or calcitonin (Calcimar), that help 645. slow the rate of bone loss and help 2. Khovidhunkit W, Shoback DM. Clinical Anniversaries effects of raloxifene hydrochloride in women. rebuild bone. Ann Internal Med 1999;130:431-439. Raloxifene joins this small group of Join Us in Celebrating

The Hughston Health Alert is a quarterly publication of the Hughston Sports Medicine Founda- tion, Inc. The Foundation’s mission is to help people of all ages attain the highest possible standards of the 50th Anniversary of musculoskeletal health, fitness, and athletic prowess. Information in the Hughston Health Alert reflects the experience and training of physicians at The Hughston Clinic, P.C., of physical therapists and athletic Dr. Jack Hughston's Practice trainers at Rehabilitation Services of Columbus, Inc., of physicians who trained as residents and fellows under the auspices of the Hughston Sports Medicine Foundation, Inc., and of research scientists and other professional staff at the Foundation. The information in the Hughston Health Alert is intended to and supplement the advice of your personal physician and should not be relied on for the treatment of an individual’s specific medical problems. Special written permission is required to reproduce, by any manner, in whole or in part, the mate- the 15th Anniversary of the rial herein contained. Send inquiries to Medical Writing, Hughston Sports Medicine Foundation, Inc., P.O. Box 9517, 6262 Veterans Parkway, Columbus GA 31908-9517 USA. Copyright 1999, Hughston Sports Medicine Foundation, Inc. ISSN# 1070-7778 Hughston Sports Medicine Hospital

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