Someone recently sent me a New York Times article I’d missed about the controversy over WHO’s FRAX tool. The article makes the point that FRAX uses only a few risk factors and doesn’t account for many, many others — including vitamin D deficiency, use of bone-eroding medications, and amount of physical activity — in determining whether a person should take drugs for their bone health.

I’m glad to finally see this point being made in the mainstream media! While FRAX represented the first step toward the idea that different people have different levels of risk for bone loss, it’s fairly rudimentary — like bashing a nail with a big rock because you don’t have a hammer. Our more comprehensive Bone Health Profile looks not only at the categories FRAX examines (in greater depth, in some cases), but also at diet, other health issues, menopause status (for women), and emotional factors like stress and worry.

Another big concern cited by the article is that FRAX itself was not meant to dictate who should be prescribed bone drugs. WHO left the decision to treat to individual physicians, and in many countries osteoporosis organizations propagated their own guidelines. In the U.S., the National Osteoporosis Foundation (NOF) developed treatment guidelines based on FRAX. The NOF recommends treatment when FRAX projects a 10-year fracture risk of more than 3% for hip fracture, or 20% combined risk of fractured hip, vertebrae, shoulder, or wrist.

At the Center for Better Bones, we see several problems with the NOF guidelines. One is that the cut-off bar for treatment is too low, and even worse, in the doctor’s office “treatment” is almost always defined as drugs (FDA-approved medical therapies)! Further, the NOF guidelines miss the point that one does not have to fracture just because they have a 3% or even 20% risk of doing so over the next 10 years. Seeking out the causes of bone weakness, correcting these causal factors, and undertaking a strong nutrition and lifestyle program, one can build bone strength and avoid needless fracture without pharmacological agents.

We at the Center for Better Bones believe that there are many causes of osteoporosis. Finding these causes and working with nature to correct them are most often the best ways to “treat” those at risk of fracture.When individuals are motivated to take charge of their bone health, they can substantially alter their fracture risk within a few years, never mind an entire decade. That’s what my Better Bones, Better Body book and the Personal Program for Better Bones are all about. I’m sorry to see that the New York Times didn’t make that point — that your risk of fracture isn’t something carved in stone, as FRAX would have you believe. I think physicians really need to understand that instead of offering drugs at the drop of a hat.

Much of the fear generated around osteoporosis stems from pictures of stooped, hump-backed, downward-looking elderly women. This vertebral deformity, often called a “dowager’s hump” and technically known as “kyphosis,” has come to be a dreaded tell-tale sign of the crippling potential of osteoporosis. New research, however, indicates that contrary to popular opinion, this feared spinal deformity does not necessarily indicate that one has a vertebral fracture. Nor does having a dowager’s hump predict the probability of a future spinal fracture.

Actually, this new Australian research is of great interest to me. In my office I have seen more than one very stooped, elderly woman whom I might well think was crippled by osteoporosis, yet her bone tests showed no such problem. While the dowager’s hump and severe kyphosis can be caused by multiple spinal fractures, it often is not. In fact, the relationship between kyphosis and spinal fracture was so weak that these Australian researchers concluded that the existence of even severe kyphosis is only of limited value in determining a person’s risk of having a vertebral deformity and is no value in determining that individual’s risk of future vertebral fracture. Spinal deformities and vertebral fractures can only be reliably diagnosed using x-ray technology or by means of vertebral fracture assessment, also known as vertebral morphometry deformity assessment. Thus, if I see someone very worried about spinal fractures, I suggest that they ask their physician for a spinal x-ray or a vertebral fracture assessment.

So, if having a dowager’s hump or kyphosis does not necessarily mean you have osteoporosis, what else might it mean? Well, the most common reason for such a hump is postural slouching associated with a loss of musculoskeletal integrity and strength. For many, standing tall and holding good posture is an exercise in itself. Other non-fracture reasons include certain diseases, developmental or congenital causes, and nutritional issues such as rickets from vitamin D deficiency.

Reference:
Prince, RL, et al. 2007. The clinical utility of measured kyphosis as a predictor of the presence of vertebral deformities. Osteoporosis International, 18:621-627.

You have probably heard that back strengthening exercises help prevent spinal osteoporotic fractures — but are all types of exercises equally beneficial? No, they are not, as clearly documented by an early Mayo Clinic study (Sinaki and Mikkelsen 1984). This study showed clearly that extension-type back-strengthening exercises effectively prevented further spinal deformation in osteoporotic women. Flexion-type exercises, on the contrary, actually increased the risk of further spinal compression and wedging.

This landmark 1984 Mayo Clinic study took 59 postmenopausal women (49–60 yrs old) with spinal osteoporosis and/or existing spinal fractures and back pain. The women were grouped into four different treatment programs (1) extension exercise (bending backwards, spine lengthening exercises); (2) flexion exercise (bending forward exercises) (3) both extension and flexion exercises, and (4) no therapeutic exercise. Spinal x-rays were analyzed before and after the mean 1.5-year study period. Although small in number, the study was large in significance. Only 16% of women doing the extension exercise experienced further spinal wedging or compression. On the other hand, a whopping 89% of those doing the flexion exercises had worsened spinal deformities, as did 53% of those doing the combined extension and flexion exercises and 67% of the non-exercisers.

Exercise is a key component of the Better Bones, Better Body® Program, and in this regard, a favorite ally is a good physical therapist who can help individuals with back pain and/or existing spinal deformities develop a safe and effective back strengthening program to help prevent new spinal fractures.

Reference:
Sinaki, M and Mikkelsen, BA. 1984. Postmenopausal spinal osteoporosis: Flexion versus extension exercises. Arch Phys Med Rehabil, 65:593–596.