Osteoporosis

Osteoporosis, which means "porous bone," is a disease characterized by low bone mass (bone thinning) that leads to fragile bones and an increased risk of fractures of the hip, spine, and wrist. Men as well as women are affected by this condition. Osteoporosis is a disease that can be prevented and treated.

Understanding Osteoporosis and Bones

Bone is living, growing tissue. It is made mostly of collagen, a protein that provides a soft framework, and calcium phosphate, a mineral that adds strength and hardens the framework.

This combination of collagen and calcium phosphate makes bone both flexible and strong, which, in turn, helps it withstand stress. More than 99 percent of the body's calcium is contained in the bones and teeth. The remaining 1 percent is found in the blood.

Throughout your lifetime, old bone is removed (a process called resorption) and new bone is added to the skeleton (a process called formation). During childhood and the teenage years, new bone is added faster than old bone is removed. As a result, bones become larger, heavier, and denser. Bone formation outpaces resorption until peak bone mass (maximum bone density and strength) is reached around age 30. After that time, bone resorption slowly begins to exceed bone formation.

There are two main types of osteoporosis: primary and secondary.

Primary

In cases of primary osteoporosis, either the condition is caused by age-related bone loss (sometimes called senile osteoporosis), or the cause may be unknown (called idiopathic osteoporosis). The term idiopathic osteoporosis is used only for people who are under the age of 70; in older people, age-related bone loss is assumed to be the cause.

Secondary

In cases of secondary osteoporosis, the loss of bone mass is caused by certain lifestyle factors, diseases, or medications. The majority of people with osteoporosis have at least one secondary cause.

Risk Factors You Cannot Change

There are a number of risk factors for osteoporosis that you cannot change, including:

• Gender. Your chances of developing osteoporosis are greater if you are a woman. Women have less bone tissue and lose bone faster than men because of the changes that happen with menopause.
• Age. The older you are, the greater your risk of osteoporosis. Your bones become thinner and weaker as you age.
• Body size. Small, thin-boned women are at greater risk for developing osteoporosis than larger women.
• Ethnicity. Caucasian and Asian women are at the highest risk of developing the disease. African-American and Hispanic women have a lower, but still significant, risk.
• Family history. Your risk for fractures may be due, in part, to heredity. People whose parents have a history of fractures also seem to have reduced bone mass and may be at risk for fractures themselves.

Risk Factors You Can Change

The good news is that there are a number of risk factors for osteoporosis you can change, including:

• Sex hormones. Abnormal absence of menstrual periods (amenorrhea), low estrogen levels (menopause), and low testosterone levels in men can bring on osteoporosis.
• Anorexia nervosa. Characterized by an irrational fear of weight gain, this eating disorder increases your risk for osteoporosis.
• Calcium and vitamin D intake. A lifetime diet low in calcium and vitamin D makes you more prone to bone loss.
• Medication use. Long-term use of glucocorticoids and some anticonvulsants can lead to loss of bone density, which can ultimately result in fractures.
• Lifestyle. An inactive lifestyle or extended bed rest tends to weaken bones.
• Cigarette smoking. Cigarettes are bad for the bones as well as the heart and lungs.
• Alcohol intake. Excessive consumption of alcohol increases the risk of bone loss and fractures.

Signs and Symptoms of Osteoporosis

People with osteoporosis often don't know they have it, simply because there are no osteoporosis symptoms in the early stages of the disease. That is what led specialists to label osteoporosis as the "silent disease."

As osteoporosis progresses, you may develop symptoms related to weakened bones, including:

• Back pain
• Loss of height and stooped posture
• A curved backbone (known as a dowager's hump)
• Fractures that may occur with a minor injury, especially of the hip, spine, or wrist.

Making a Diagnosis Before Symptoms Develop

Specialized tests called bone density tests can measure bone density in various sites of the body, thereby predicting those who are at greater risk of developing symptoms of osteoporosis. A bone density test can:

• Detect osteoporosis before a fracture occurs
• Predict your chances of fracturing in the future
• Determine the rate of bone loss
• Monitor the effects of treatment if the test is conducted at intervals of a year or more.

The most common bone mineral density test is dual-energy x-ray absorptiometry (DEXA). The results of the DEXA test are scored in comparison to the bone mineral density (BMD) of young, healthy individuals, resulting in a measurement called a T-score. If your T-score is -2.5 or lower, you are considered to have osteoporosis and, therefore, are at high risk for a fracture. T-scores between -1.0 and -2.5 are generally considered to show osteopenia (a reduction in bone mass that is not as severe as with osteoporosis). The risk of fractures is generally lower in people with osteopenia when compared to those with osteoporosis. However, if bone loss continues in a person with osteopenia, the risk for fracture increases, too.

The United States Preventive Services Task Force recommends that all women age 65 or older routinely have a bone mineral density test to screen for osteoporosis. If you have a higher risk for fractures, routine screening should begin at age 60.

Osteoporosis Treatment

A comprehensive treatment program for osteoporosis deals with:

• Proper nutrition
• Exercise
• Safety issues to prevent falls that may result in fractures.

In addition, your physician may prescribe medication as part of your osteoporosis treatment to slow or stop bone loss, increase bone density, and reduce fracture risk.

Nutrition

The foods we eat contain a variety of vitamins, minerals, and other important nutrients that help keep our bodies healthy. All of these nutrients are needed in balanced proportion. In particular,calcium and vitamin D are needed for strong bones and for your heart, muscles, and nerves to function properly.

Exercise

Exercise is an important component of an osteoporosis prevention and treatment program. Exercise not only improves your bone health, but it also increases muscle strength, coordination, and balance, and leads to better overall health. While exercise is good for someone with osteoporosis, it should not put any sudden or excessive strain on your bones. As extra insurance against fractures, your doctor can recommend specific exercises to strengthen and support your back.

Medications

There are a number of medications currently approved for treating osteoporosis, including:

• Alendronate (Fosamax^®)
• Risedronate (Actonel^®)
• Ibandronate (Boniva^®)
• Calcitonin (Miacalcin^®, Fortical^®)
• Raloxifene (Evista^®)
• Estrogen therapy (ET) or hormone therapy (HT)
• Parathyroid hormone or teriparatide (Forteo^®).

Alendronate (Fosamax)

This drug belongs to a class of drugs called bisphosphonates and is approved for both osteoporosis prevention and treatment. It is used to treat bone loss from the long-term use of osteoporosis-causing medications and is also used for osteoporosis in men. In postmenopausal women, it has shown to be effective at reducing bone loss, increasing bone density in the spine and hip, and reducing the risk of spine and hip fractures.

Risedronate (Actonel)

Like alendronate, risedronate is also a bisphosphonate. It is approved for:

• Osteoporosis prevention and treatment
• Bone loss from the long-term use of osteoporosis-causing medications
• Osteoporosis in men.

Risedronate has been shown to slow bone loss, increase bone density, and reduce the risk of spine and non-spine fractures.

Ibandronate (Boniva)

Ibandronate is approved for the prevention and treatment of postmenopausal osteoporosis. Taken as a once-a-month pill, ibandronate should be taken on the same day each month. Ibandronate reduces bone loss, increases bone density, and reduces the risk of spine fractures.

Calcitonin (Miacalcin, Fortical)

Calcitonin is a naturally occurring hormone involved in calcium regulation and bone metabolism. Calcitonin can be injected or taken as a nasal spray. In women who are at least five years beyond menopause, it slows bone loss and increases spinal bone density. Women report that it also eases pain associated with bone fractures.

Raloxifene (Evista)

This drug is a selective estrogen receptor modulator (SERM) that has many estrogen-like properties. It is approved for osteoporosis treatment and prevention, and can prevent bone loss at the spine, hip, and other areas of the body. Studies have shown that it can decrease the rate of vertebral fractures by 30 percent to 50 percent.

Estrogen Therapy (ET) or Hormone Therapy (HT)

These drugs, which have been used to treat the symptoms of menopause, also are used to prevent bone loss. However, recent studies suggest that this might not be a good option for many women. The U.S. Food and Drug Administration (FDA) has made the following recommendations for taking ET and HT:

• Take the lowest possible doses of ET or HT for the shortest period of time to manage symptoms of menopause
• Talk with your doctor about using other osteoporosis medications instead.

Parathyroid Hormone or Teriparatide (Forteo)

Forteo is approved for treating osteoporosis in postmenopausal women and for men who are at high risk for a fracture. It helps new bone to form and increases bone density. In postmenopausal women, it has been shown to reduce fractures in the spine, hip, foot, ribs, and wrist. In men, it can reduce fractures in the spine. It can be taken as a daily injection for up to 24 months.

Osteoporosis Research

The field of research on osteoporosis has grown in recent years. This has resulted in significant advances in determining the causes of osteoporosis, assessing risk factors, and creating new treatment methods. Several initiatives that are focused on skeletal biology should help in developing strategies to maintain and enhance bone density in childhood.

Rheumatoid Arthritis

Rheumatoid arthritis is an autoimmune disease that causes pain, swelling, stiffness, and loss of function in the joints. It has several special features that make it different from other kinds of arthritis. For example, it generally occurs in a symmetrical pattern, meaning that if one knee or hand is involved, the other one also is. Rheumatoid arthritis often affects the wrist joints and the finger joints closest to the hand.

Scientists estimate that about 2.1 million people, or between 0.5 percent and 1 percent of the U.S. adult population, have rheumatoid arthritis. Interestingly, some recent studies have suggested that the overall number of new cases may actually be going down. Scientists are investigating why this may be happening.

Rheumatoid arthritis occurs in all races and ethnic groups. Although the disease often begins in middle age and occurs with increased frequency in older people, children and young adults also develop it. Like some other forms of arthritis, rheumatoid arthritis occurs much more frequently in women than in men. About two to three times as many women as men have the disease.

Based on recent research, it is believed that the main rheumatoid arthritis causes may be linked to a combination of:

• Genetic factors
• Environmental factors
• Hormones.

Genetic (Inherited) Factors

About 10 percent of people with rheumatoid arthritis have a first-degree relative with the disease. This suggests that genetics plays a role in the cause of the disease. Rheumatoid arthritis research scientists have also discovered that certain genes known to play a role in the immune system are associated with a tendency to develop rheumatoid arthritis. Some people with rheumatoid arthritis do not have these particular genes; and still others have these genes but never develop the disease.

These somewhat contradictory data suggest that a person's genetic makeup plays an important role in determining if he or she will develop rheumatoid arthritis, but that it is not the only factor. What is clear, however, is that more than one gene is involved in determining whether a person develops rheumatoid arthritis and how severe the disease will become.

Environmental Factors

As with other autoimmune diseases, many scientists think that something must occur to trigger the disease process in people whose genetic makeup makes them susceptible to rheumatoid arthritis. A viral or bacterial infection appears likely, but the exact agent is not yet known. Given that rheumatoid arthritis occurs all over the world, it is thought that this organism must be everywhere. Scientists have studied bacteria such as mycoplasmas, as well as viruses such as cytomegalovirus, parvovirus, Epstein-Barr virus, and the rubella virus. However, to date there have been no convincing data to show that these viruses can cause rheumatoid arthritis.

Also, keep in mind that this does not mean that rheumatoid arthritis is contagious; a person cannot catch the disease from someone else.

Hormones

Some scientists also think that a variety of hormonal factors may be a possible rheumatoid arthritis cause. This is based on the fact that women are more likely to develop rheumatoid arthritis than men, pregnancy may improve the disease, and the disease may flare after a pregnancy. Hormones, or possibly deficiencies or changes in certain hormones, may promote the development of rheumatoid arthritis in a genetically susceptible person who has been exposed to a triggering agent from the environment.

Final Thoughts on the Rheumatoid Arthritis Causes

Even though researchers do not have all the answers or know the exact cause or causes of rheumatoid arthritis, one thing is certain: rheumatoid arthritis develops due to a combination of many factors. Researchers are trying to understand these factors and how they work together.

Signs and Symptoms of Rheumatoid Arthritis

In about two out of every three people, early symptoms are pretty vague. These symptoms can include things such as:

• Fatigue
• Occasional fevers
• A general sense of not feeling well
• A decreased appetite.

These early symptoms of rheumatoid arthritis may continue for weeks or months before joint symptoms begin, making a diagnosis quite difficult.

About one in every three people will have early symptoms that affect one or two joints. About 10 percent of people diagnosed with rheumatoid arthritis will have a very rapid progression, with early symptoms that involve multiple joints along with fever, enlarged lymph nodes, and an enlarged spleen.

Joint Symptoms

For a person with rheumatoid arthritis, symptoms that affect the joints usually differ from other forms of arthritis. Within the affected joints, common symptoms of rheumatoid arthritis include:

• Tender, warm, and swollen joints
• Pain that is worse with movement
• A decrease in motion
• A symmetrical pattern affecting both the right and left sides of the body
• Pain and stiffness lasting for more than 30 minutes in the morning or after a long rest.

Other Symptoms

As rheumatoid arthritis progresses, a person may develop other symptoms outside of the joint. Some of these other rheumatoid arthritis symptoms may include:

• Rheumatoid nodules, which are small lumps. These can occur under your skin at pressure points. They can occur anywhere, but some common areas for rheumatoid nodules include the elbow, wrist, Achilles tendon, and the back of the head.

• Loss of strength in the muscles that surround the affected joints.

• Dry eyes and mouth.

• Anemia, which is a decrease in the production of red blood cells.

• Osteoporosis or osteopenia, which is thinning of bones.

• Very rarely, inflammation of the blood vessels, the lining of the lungs, or the sac enclosing the heart.

Progression of Rheumatoid Arthritis Symptoms

Rheumatoid arthritis affects people differently. For some people with rheumatoid arthritis, symptoms last only a few months or a year or two and go away without causing any noticeable damage. Other people have mild or moderate forms of the disease, with periods of worsening symptoms (called flares) and periods in which they feel better (called remissions). Others may have a severe form of rheumatoid arthritis that is active most of the time, lasts for many years or a lifetime, and leads to serious joint damage and disability.

Diagnosing Rheumatoid Arthritis

Rheumatoid arthritis can be difficult to diagnose in its early stages for several reasons. First, there is no single test for the disease. In addition, symptoms differ from person to person and can be more severe in some people than in others. Also, symptoms can be similar to those of other types of arthritis and joint conditions, and it may take some time for other conditions to be ruled out.

Finally, the full range of rheumatoid arthritis symptoms develops over time, and only a few signs may be present in the early stages.

To help in diagnosing rheumatoid arthritis and to rule out other conditions, healthcare providers use a variety of tools. These include:

• Medical history
• Physical examination
• Laboratory tests
• X rays

Medical History

The medical history is the patient's description of symptoms and when and how they began. Good communication between the patient and healthcare provider is especially important here. For example, the patient's description of pain, stiffness, and joint function, and how these change over time is critical to the healthcare provider's initial assessment of the disease and how it progresses.

Physical Examination

The physical exam includes the doctor's examination of the joints, skin, reflexes, and muscle strength.

Laboratory Tests

There is no one single test that a healthcare provider can use to make a rheumatoid arthritis diagnosis, so he or she will use a combination of tests. One common test is for rheumatoid factor, an antibody (a special protein made by the immune system that normally helps fight foreign substances in the body) that is present eventually in the blood of most people with rheumatoid arthritis.

However, not all people with this condition test positive for rheumatoid factor. This is especially true early in the disease. Also, some people test positive for rheumatoid factor, yet never develop rheumatoid arthritis.

Other common laboratory tests include a white blood cell count, a blood test for anemia, and a test of the erythrocyte sedimentation rate (often called the sed rate or ESR), which measures inflammation in the body. C-reactive protein is another common test that measures disease activity.

X-rays

X-rays are used to determine the degree of joint destruction. They are not useful in the early stages of rheumatoid arthritis before bone damage is evident, but they can be used later to monitor the progression of the disease.

Final Thoughts

Diagnosing and treating rheumatoid arthritis requires a team effort involving the patient and several types of healthcare professionals. A person can go to his or her family doctor, an internist, or a rheumatologist to seek medical attention. A rheumatologist is a doctor who specializes in arthritis and other diseases of the joints, bones, and muscles.

Rheumatoid Arthritis Treatment

Healthcare providers use a variety of approaches when treating rheumatoid arthritis. These approaches are used in different combinations and at different times during the course of the disease, and are chosen according to the person's individual situation. No matter what types of treatment the healthcare provider and patient choose, however, the goals are the same:

• Relieving pain
• Decreasing inflammation
• Slowing down or stopping joint damage
• Improving a person's sense of well-being and ability to function.

Current treatment options for rheumatoid arthritis include:

• Lifestyle changes
• Medications
• Surgery
• Routine monitoring and ongoing care.

Keep in mind that good communication between the patient and healthcare providers is necessary for effective rheumatoid arthritis treatment. Talking to the healthcare providers can help ensure that exercise and pain management programs are provided as needed and that drugs are prescribed appropriately. Ultimately, however, successful treatment begins with you. Studies have shown that patients who are well-informed and participate actively in their own care have less pain and make fewer visits to the doctor than do other patients with rheumatoid arthritis.

Lifestyle Changes

As part of treating rheumatoid arthritis, certain activities can help improve a person's ability to function independently and maintain a positive outlook. These activities can include:

• Rest and exercise
• Joint care
• Stress reduction
• Helpful diet
• Climate.

Rest and Exercise

People with rheumatoid arthritis need a good balance between rest and exercise, with more rest when the disease is active and more exercise when it is not. Rest helps to reduce active joint inflammation and pain and to fight fatigue. While the length of time needed for rest will vary from person to person, shorter rest breaks every now and then are generally more helpful than long times spent in bed.

Exercise is important for maintaining healthy and strong muscles, preserving joint mobility, and maintaining flexibility. Exercise can also help people sleep well, reduce pain, maintain a positive attitude, and lose weight. Exercise programs should be planned and executed based on the person's physical abilities, limitations, and changing needs.

Joint Care

Some people find using a splint for a short time around a painful joint reduces pain and swelling by supporting the joint and letting it rest. Splints are used mostly on wrists and hands, but may also be used on ankles and feet. A doctor or a physical or occupational therapist can help a person choose a splint and make sure it fits properly. Other ways to reduce stress on joints include self-help devices (for example, zipper pullers, long-handled shoe horns, etc.); devices to help with getting on and off chairs, toilet seats, and beds; and changes in the ways that a person carries out daily activities.

Stress Reduction

People with rheumatoid arthritis face emotional challenges as well as physical ones. The emotions they feel because of the disease (including fear, anger, and frustration) combined with any pain and physical limitations can increase their stress level. Although there is no evidence that stress plays a role in causing rheumatoid arthritis, it can make living with the disease difficult at times. Stress may also affect the amount of pain a person feels. There are a number of successful techniques for coping with stress. Regular rest periods can help, as can relaxation, distraction, or visualization exercises. Exercise programs, participation in support groups, and good communication with the healthcare team are other ways to reduce stress.

Healthful Diet

With the exception of several specific types of oils, there is no scientific evidence that any specific food or nutrient helps or harms people with rheumatoid arthritis. However, an overall nutritious diet with enough -- but not excessive quantities of -- calories, protein, and calcium is important.

Some people may need to be careful about drinking alcoholic beverages because of the medications they take for rheumatoid arthritis. Those taking methotrexate may need to avoid alcohol altogether, since one of the most serious long-term side effects of methotrexate is liver damage.

Climate

Some people notice that their arthritis gets worse when there is a sudden change in the weather. However, there is no evidence that a specific climate can prevent or reduce the effects of rheumatoid arthritis. Moving to a new place with a different climate usually does not make a long-term difference in a person's rheumatoid arthritis.

Treating Rheumatoid Arthritis With Medications

For most people who have rheumatoid arthritis, treatment also involves taking medications. Some rheumatoid arthritis medicines are used only for pain relief, while others are used to reduce inflammation. There is also another class of medications, often called disease-modifying antirheumatic drugs (DMARDs), that is used to try to slow down the course of the disease.

Some important factors for deciding which medication is most appropriate as part of a treatment plan for rheumatoid arthritis include the:

• Person's general condition
• Current and predicted severity of the illness
• Length of time he or she will take the drug
• Drug's effectiveness and potential side effects.

Biologic response modifiers are new drugs that are used in rheumatoid arthritis treatment. They can help reduce inflammation and structural damage to the joints by blocking the action of cytokines, proteins in the body's immune system that trigger inflammation during normal immune responses. Three of these drugs -- etanercept (Enbrel^®), infliximab(Remicade^®), and adalimumab (Humira^®) -- reduce inflammation by blocking the reaction of TNF-alpha molecules. Another drug, calledanakinra (Kineret^®), works by blocking a protein called interleukin 1 (IL-1) that is seen in excess in people with rheumatoid arthritis.Abatacept (Orencia^®) is a new biologic response modifier that seems to prevent T cells from becoming active. T cells are a type of white blood cell (leukocytes) that play an important role in rheumatoid arthritis.

For many years, healthcare providers initially prescribed aspirin or other pain-relieving drugs for rheumatoid arthritis, as well as rest and physical therapy. Other more powerful drugs were prescribed only if the disease worsened.

Today, however, many healthcare providers have changed their approach, especially for people with severe, rapidly progressing rheumatoid arthritis. Studies show that early treatment for rheumatoid arthritis with more powerful drugs and the use of drug combinations instead of one medication alone may be more effective at reducing or preventing joint damage. Once the disease improves or is in remission, the healthcare provider may gradually reduce the dosage or prescribe a milder medication.

Surgery

Several types of surgery are available for people with severe joint damage. The primary purpose of these procedures is to reduce pain, improve the affected joint's function, and improve the person's ability to perform daily activities.

Surgery is not for everyone, however, and the decision should be made only after careful consideration by the patient and healthcare provider. Together, they should discuss the person's overall health, the condition of the joint or tendon that will be operated on, and the reason for, as well as the risks and benefits of, the surgical procedure. Cost may be another factor.

Some surgical procedures that are commonly performed to treat rheumatoid arthritis include:

• Joint replacement
• Tendon reconstruction
• Synovectomy.

Joint Replacement

This is the most frequently performed surgery for treating rheumatoid arthritis, and it is done primarily to relieve pain and improve or preserve joint function. Artificial joints are not always permanent and may eventually have to be replaced. This may be an important consideration for young people.

Tendon Reconstruction

Rheumatoid arthritis can damage and even rupture tendons, the tissues that attach muscle to bone. Tendon reconstruction is a type of surgery used most frequently on the hands, and it reconstructs the damaged tendon by attaching an intact tendon to it. This procedure can help to restore hand function, especially if the tendon is completely ruptured.

Synovectomy

In this surgery, the healthcare provider actually removes the inflamed synovial tissue. Synovectomy by itself is seldom performed now because not all of the tissue can be removed, and it eventually grows back. Synovectomy is done as part of reconstructive surgery, especially tendon reconstruction.

Routine Monitoring and Ongoing Care

Regular medical care is important to monitor the course of the disease, determine the effectiveness and any negative effects of medications, and change therapies as needed. Monitoring typically includes regular visits to the doctor. It also may include blood, urine, and other laboratory tests and x-rays.

People with rheumatoid arthritis may want to discuss preventing osteoporosis with their healthcare provider as part of their long-term, ongoing care. Osteoporosis is a condition in which bones become weakened and fragile. Having rheumatoid arthritisincreases the risk of developing osteoporosis for both men and women, particularly if a person takes corticosteroids. Such people may want to talk with their healthcare provider about the potential benefits of calcium and vitamin D supplements, hormone therapy, or other treatments for osteoporosis.

Alternative and Complementary Therapies

Special diets, vitamin supplements, and other alternative approaches have been suggested for rheumatoid arthritis treatment. Although many of these approaches may not be harmful in and of themselves, controlled scientific studies either have not been conducted on them or have found no definite benefit to these therapies. Some alternative or complementary approaches may help the person cope or reduce some of the stress associated with living with a chronic illness.

As with any therapy, people should discuss the benefits and drawbacks with their healthcare provider before beginning an alternative or new type of therapy. If he or she feels the approach has value and will not be harmful, it can be incorporated into the treatment plan. However, it is important not to neglect regular healthcare.

As treatment progresses, other professionals often help. These may include:

• Nurses
• Physical or occupational therapists
• Orthopedic surgeons
• Psychologists
• Social workers.

Rheumatoid Arthritis Treatment Begins With You

Studies have shown that people who are well-informed and participate actively in their own care have less pain and make fewer visits to the doctor than do other people with rheumatoid arthritis. Patient education and arthritis self-management programs, as well as support groups, help people to become better-informed and to participate in their own care.

Self-management programs teach about rheumatoid arthritis and its treatments, exercise and relaxation approaches, communication between patients and healthcare providers, and problem solving. Rheumatoid arthritis research on these programs has shown that they help people:

• Understand the disease
• Reduce their pain while remaining active
• Cope physically, emotionally, and mentally
• Feel greater control over the disease and build a sense of confidence in their ability to function and lead full, active, and independent lives.