AGING
January 15, 2008

Osteoporosis and Osteoarthritis

John E. Morley, M.B., B.Ch. and Sheri R. Colberg, Ph.D.
Ms. Colberg is an exercise physiologist and associate professor of exercise science at Old Dominion University in Norfolk, Virginia. A diabetes researcher with almost four decades of practical experience as a type 1 diabetic exerciser, she is a Fellow of the American College of Sports Medicine, a professional member of the American Diabetes Association, and the author of three books on diabetes.


Editor's Note: Keeping bones healthy is important, but if you develop osteoporosis, you are going to want to do everything you can to build bone density back up. Exercise and diet are still crucial, but they are not likely to be enough on their own. Luckily, hormones and several new drugs can help.

The following is an excerpt from a new book by The Doctor's Senior Living specialist, gerontologist, Dr. John Morley: The Science of Staying Young, 10 Simple Steps to Feeling Younger than You Are in 6 Months or Less, written with Sheri R. Colberg, Ph.D. (McGraw-Hill, 2008). Used by permission.



Hormones and Bone Health
It is well established that estrogen is essential for the maintenance of normal bone minerals. Despite the recent controversy from the Women's Health Initiative, for reasons of bone health alone, women experiencing early menopause should consider taking supplemental estrogen at least until the age that most women go through it, about 52 years. In addition, women with low bone minerals and a normal menopausal age should take estrogen (and in some cases progesterone) for five years after menopause, but not after age 60. Appropriate estrogen dosing is discussed in Step 3.

As for testosterone, it appears that this androgenic hormone may stimulate bone formation, while estrogen only prevents its loss. Males with low testosterone levels may need to take this hormone to protect their bones, but it may also improve bone strength in women. A medication called Livial is a unique estrogen-progesterone-testosterone agent that may be particularly useful for some women to reduce hot flashes and improve bone mineral content. It is not available in the United States, but is currently sold in the rest of the world.

Treating Osteoporosis with Other Medications
In addition to making healthy dietary and other lifestyle changes to improve your bone health, you may also need to consider using prescribed medications that can enhance bone mineral content. Drugs for treating osteoporosis include bisphosphonates (Fosamax, Actonel, and Boniva), raloxifene (Evista), calcitonin , and parathyroid hormone analogs. The first two classes of drugs are taken by mouth. Calcitonin is a naturally-occurring hormone produced by your parathyroid gland, but a synthetic form is available as nasal spray. Similarly, an analog of parathyroid hormones given by injection can help stimulate your bones to get stronger. Some other new drugs are in the pipeline and include medications that may work as antibodies to your body's natural hormones that cause bone thinning.

At present, most women and men with thinning bones (or at high risk) should minimally take a bisphosphonate, along with supplemental calcium and vitamin D for at least five years. A controversy over whether taking bisphosphonates for longer may actually lead to the development of more brittle bones (the opposite of the desired effect) exists. If you have been taking them for longer than this time frame, you should discuss whether to continue their use with your doctor.

Maintain Optimal Joint Health
Arthritis is the painful inflammation of a joint or joints, and having to live with the daily pain it causes can make you feel a lot less youthful. The most common type is osteoarthritis caused by degeneration of bony joint surfaces, usually in the knees, hips, spine, hands and toes. Often described as "wear and tear" arthritis, it affects more than 15 million Americans and is more common in joints that have been previously injured, particularly traumatically (through contact sports injuries). In addition, lower extremity joints are more likely to become arthritic if you're overweight since carrying around more weight puts additional stress on cartilage in hip and knee joints.

What Causes Arthritis?
Arthritis can result from trauma or from repetitive use, although often no single cause is identifiable. Joints, formed by the juxtaposition of two or more bones with cartilage coats on their ends, normally function to provide flexibility, stability, support, and protection to the skeleton, allowing movement of limbs. In a healthy joint, this coating maintains the separation between bones, allowing joints to move smoothly and without pain. In the early stages of this type of arthritis, however, the cartilage's surface becomes swollen (inflamed), forming tiny crevasses that hinder movement. A loss of elasticity in the cartilage also makes it more vulnerable to further damage, and outgrowths known as bone spurs often begin to form around its edges. Other associated joint structures, such as the synovial fluid in the middle, tendons, and ligaments, can also become inflamed. In advanced cases, the cartilage cushion is completely lost, limiting joint mobility.

How Can You Tell If You Have Arthritis?
Arthritis is easily identifiable by the symptoms listed [below], although their degree varies widely among individuals. It can cause pain in the affected joint or joints after repeated use, especially later in the day, or you may experience swelling, pain, and stiffness after long periods of inactivity (e.g., after sleep or sitting long periods) that subsides with activity.

Symptoms of Arthritis
  • Pain, made worse by cool, damp weather
  • Crackling or popping in the affected joints (most commonly knees)
  • Enlarged, swollen joints, often tender when touched
  • Stiffness and restricted movement in affected joints
  • Unstable joints that move too far or in the wrong direction

Symptoms also vary with the affected joint. For instance, if you have knee arthritis, you may experience problems with that joint locking up, especially when stepping up or down. Hip problems usually make you limp, while affected finger joints often result in reduced strength and movement, making simple tasks such as buttoning clothes or opening jars difficult. An arthritic spine can cause neck and low back pain, along with weakness and numbness, particularly if you have developed bony spurs there. Affected finger joints can also result in hard, bony enlargements. The pain that you feel doesn't come from the joint cartilage surfaces themselves as they contain no nerve endings, but rather from the irritated nerves in adjacent stretched or inflamed areas. You can also experience what is known as "referred pain," meaning that you feel it somewhere other than in the affected joint. For example, an arthritic spine can cause pain in your neck, arms, or legs. Pain is only continuous when almost all of the cartilage surfaces of joints have been eroded, at which point it is indicative of advanced arthritis.

Will Exercise Help or Hurt My Joints?
To prevent painful flare-ups, avoid doing intense activities that can further injure the joint's bony surfaces. Moderate aerobic exercise can be beneficial as long as it is performed at an intensity that is not injurious. For example, even a six-month weight loss and walking program has been shown to result in lesser arthritic pain in overweight and obese postmenopausal women with knee arthritis. Vigorous running, however, would likely serve to further damage knee joints in that case.

To further protect arthritic joints, focus on strengthening surrounding muscles that will support and protect them. For instance, for your knees, work on strengthening both groups of muscles in your thigh that affect knee movement including your quadriceps in the front (knee extensors) and hamstrings in the back of your thigh (flexors). In addition, non-weight-bearing ones like stationary cycling, aquatic activities, and light to moderate resistance work that put lower amounts of stress on joints should result in less pain and fewer arthritis-related problems.

Treatment of Arthritis
Much of the treatment for arthritis involves no prescriptions at all, focusing instead on ways to relieve painful joints through more practical changes or treatments. Try any or all of the suggestions given [below] that pertain to your affected joints to help prevent and alleviate pain without the need for additional medications.

Non-Medication Treatments of Arthritic Pain
  • Participate in regular, moderate aerobic exercise
  • Perform strengthening and full range of motion exercises for painful joints
  • Receive massage therapy on muscles surrounding affected joints
  • Use heat and cold packs whenever pain is bothersome and after exercise
  • Use special gadgets to open jars to reduce stress on finger joints
  • Use athletic tape around an arthritic knee to support and stabilize it
  • Wear wedged insoles in your shoes for hip or knee problems (or orthotics, particularly if you have one leg longer than the other)
  • Lose weight (through exercise primarily) to alleviate lower extremity arthritis pain
  • Use a cane or walking stick with painful hips or knees

Medications to Manage Arthritic Pain
If you need additional relief, prescription and non-prescription drugs are also available to help alleviate your pain. Your best bet is to start with an over-the-counter pain reliever, such as Tylenol. If this medication doesn't work, try taking nonsteroidal anti-inflammatory drugs (NSAIDs) like Advil and Nuprin, Aleve, or aspirin in recommended doses. The main problem with NSAIDs is that they can cause stomach problems and kidney damage over time, and if you already have pain from arthritis, you will likely need to use these drugs for many years.

For painkillers to work effectively, you must take them regularly, not just when you can no longer stand the pain. It's particularly important to take a dose before going to bed so that you don't wake up stiff and sore the next morning, particularly at the end of a day when you have been more active than usual.

In rare cases of extreme pain, you can ask your physician to prescribe stronger pain medications, but be aware that they can be addictive and must be used with caution. Moreover, at least one anti-inflammatory prescription pain medication (Vioxx) was recently taken off the market due to concerns that it minimally doubled the risk of heart attacks and stroke compared with older, non-prescription pain medications like Aleve. A mechanistically-similar drug, Celebrex, is still available by prescription, however.

Keep in mind that any medications you take to control your pain, even over-the-counter ones, have the potential to interact with drugs that you may be taking for other health problems. Always be certain to let your doctor know what medicines you're taking so that appropriate dosing and scheduling of all of your drugs can be coordinated.

Dietary and Herbal Remedies
Dietary changes that can alleviate inflammation may help reduce arthritic pain, although many of these remedies remain unproven. For example, some research has shown that foods rich in omega-3 fatty acids (like fish and walnuts) and the spices ginger and turmeric may help reduce inflammation, while antioxidant-rich plant foods can potentially help reduce tissue damage from inflammation. Thus, you may benefit by adding oily fish and other sources of omega-3 fatty acids, along with plenty of antioxidant-rich vegetables and fruits, to your daily diet.

The jury is still out on herbal remedies, such as supplementing with glucosamine sulfate and chondroitin, two natural treatments for arthritis, but the latest research doesn't look too promising. In addition, certain natural herbs and spices, such as ginger, holy basil, turmeric, green tea, rosemary, scutlellaria and huzhang, are thought to contain naturally occurring anti-inflammatory compounds known as COX-2 inhibitors (also found in prescription Celebrex and previously Vioxx). However, the benefit of any of these dietary supplements for arthritic pain has yet to be proven with scientific trials.

Do You Have to Have Surgery?
If you reach the point where your pain is severe and joint function is inadequate due to your arthritis, you should seriously consider having surgery. While this option previously was only a last resort, it's now becoming an earlier, effective option for treating chronic arthritic pain, particularly of the knee. Many types of surgical procedures are available to treat different joints, with the most well known being artificial joint replacement for completely destroyed joints, but other, less dramatic surgical procedures may treat arthritis in early stages and slow the progression of the disease. The good news is that this condition doesn't always worsen over time. You may find that your symptoms stabilize, and even if it progresses, it may do so very slowly, giving you plenty of time to explore other options.

Technological advances in materials, operative procedures, product design and manufacturing processes have brought joint replacement surgeries into the new millennium with a flourish. Surgical techniques are becoming more successful every day due to new bone substitutes, specialized alloys, and innovative designs for replacement joints. In the near future, you may be able to look forward to minimally invasive joint replacement surgeries and more, so stay tuned.

A Final Word...
Osteoporosis, or thinning bones, can result in fractures that can severely limit your ability to function and quality of life. The good news is that this disease is largely preventable with adequate amounts of calcium and vitamin D, participation in regular weight-bearing exercise like walking or resistance training, dietary improvements, and hormone replacement therapies. Pain from arthritis can also greatly lower how good you feel, but it can be effectively controlled through a variety of non-medicinal and medicinal means, including exercise, dietary changes, pain relievers, anti-inflammatory drugs, and surgical options, that can help you feel more youthful for longer.

Read more about the science of staying young, 10 Simple Steps to Feeling Younger than You Are in 6 Months or Less Copyright ©2008 by John E. Morley and Sheri R. Colberg. Reprinted by permission of the authors.
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