Fractures & Healing Archives

The New York Times got it wrong on spinal fractures

June 30, 2011/0 Comments/in Fractures & Healing /by Dr. Susan E. Brown

Today, I read with dismay The New York Times’ health column about vertebral compression fractures. In my opinion, it presented an inaccurate picture of what’s happening when it comes to spinal fractures. I want to address some of the points that stood out for me because I feel this article spreads a lot of fear where it’s just not necessary — and as I mentioned in a recent post, fear itself is damaging to bone!

First, let’s look at the statement that “by age 80, two in every five women [or 40%] have had one or more vertebral compression fractures.” Similar statistics have been bandied about for years, but when I took the time to look for hard data supporting them a few years ago, I found it very difficult to substantiate such high numbers. The sole large-scale study that looked at long-term risk of vertebral fractures, a review by J.A. Cauley and colleagues that came out in 2007, actually debunks this statement. As I noted in my article on spinal fractures at the time, “The results of this study suggest that earlier estimates of spinal vertebral fracture incidence have overestimated real fracture incidence. Over fifteen years, from age 68 to 84, only 18% of all US Caucasian women experienced a vertebral fracture. Overall, counting those who entered the study with an existing vertebral fracture, a little over 26% of all women had radiological evidence of a spinal fracture by age 84. This figure is significant, yet not as worrisome as the 35‐50% estimate previously reported.”

I also take issue with the statement that “vertebral fractures are a telltale sign of bone loss.” They’re not — they’re a sign of bone weakness, and there is a difference between the two! While low bone density does increase the risk of fracture, most fractures occur in persons whose bone mineral density is above the osteoporotic range. The strongest predictors of fracture in the Cauley study were advancing age, having low body weight, and the presence of a prior bone fracture — not low bone mineral density.

Now, I have been arguing for years that bone mineral density alone doesn’t predict fracture risk, and the study on which this article is based seems to agree with that assessment on its surface. The study’s authors note that the presence of vertebral fractures in women whose bone density isn’t osteoporotic means that the true diagnosis should be osteoporosis, not osteopenia — and with that, I’d agree. But the follow up statement shows where all this is truly headed: “Asked if such women should receive bone-preserving medication, Dr. Ensrud said emphatically, ‘Yes!’” This position is in direct contrast to the recommendations of the U.S. Surgeon General — that persons with bone loss should be directed to make changes to their dietary and exercise habits first, then assessed and treated for the cause of the bone loss, and then put on bone medications if the situation warrants. (The implicit assumption of Dr. Ensrud’s response is that bone drugs are always warranted.)

The idea of looking for the causes behind skeletal weakness is not even suggested, and the word “exercise” doesn’t appear in the New York Times’ article until the very last line. Yet numerous studies show low vitamin D levels to be a major cause of bone loss and weakening among most of those who fracture. Exercise, as countless more studies have shown, should be the first line of defense against osteoporosis and fractures — and considering that a Mayo Clinic study has shown a 300% reduction in risk of new vertebral fractures from simple back strengthening exercises (far more than ANY bone drug can claim), it is disturbing that Fosamax is mentioned so much more prominently than exercise.

I could go on (and on), but rather than write a novella, I’ll state my primary issue thus: The overall message is that multitudes of postmenopausal women are destined to fracture in their spine, and that they should immediately be given bone drugs for even a minor, unfelt, spinal deformity defined as a “fracture”. I would hope for a more balanced, public-interest analysis of this important health issue from one of the most important news outlets in the United States, if not the world.

One other note before I stop — I also find it troubling that all of these messages are aimed primarily at women. Studies in the U.S., Canada, and several European countries show that older men often have “silent” vertebral fractures (only seen upon X-ray) just as frequently as women do, yet the article makes no mention of looking for these hidden fractures in men and giving them drugs for these symptom-less vertebral deformities.

But here’s the bottom line: women and men with osteoporosis, even those found to have a “silent” symptom-less vertebral deformity in old age, need not automatically be given bone medications. It has been the position of the U.S. government’s top health official for most of the past decade that medication is the last resort, not the first! And that is a message that I hope all my readers get — and pass along.

References:

Brody, J.E. 2011. Along the spine, women buckle at breaking points. New York Times June 27, 2011.

Cauley, J. A., Hochberg, M. C., Lui, L. Y., et al. 2007. Long‐term risk of incident vertebral fractures. JAMA 298(23):2761‐2767.

O’Neill T. W., Felsenberg D., Varlow J., et al. 1996. The prevalence of vertebral deformity in European men and women: the European Vertebral Osteoporosis Study. J. Bone Miner. Res. 11:1010.

Brown, S. E. 2008. Spinal vertebral fractures among US Caucasian women: New statistics and new insights. URL: https://www.betterbones.com/wp-content/uploads/2016/11/spinalvertebralfracture.pdf.

Davies K. M., Stegman M. R., Heaney R. P., Recker R. R. 1996. Prevalence and severity of vertebral fracture: the Saunders County Bone Quality Study. Osteoporos. Int. 6:160.

New data on declining fracture rates

June 20, 2011/0 Comments/in Fractures & Healing /by Dr. Susan E. Brown

In the last few years, I have been reporting about the decreased rates of osteoporotic fracture in the US, Canada, and other highly industrialized countries. I have also noted that $Hip fracture$ these reductions are not due to the use of osteoporosis drugs. New data from Denmark confirms the same positive trend in this Scandinavian country.

Between 1997 and 2006 the hip fracture incidence rate in Denmark declined by 20% in men and 22% in women. During this same time period, use of osteoporosis drugs increased only 1.8% in women and 0.2% in men aged 60+.

As the investigators report, the number of prevented hip fractures that could be attributed to drug therapy was only 1.3% in men and 3.7% in women.

So what’s behind Denmark’s drop in hip fractures?

Well, researchers are still scratching their heads, but my vote would be increased awareness about — and use of — vitamin D. As I noted in a 2009 medical journal publication, there is good data to suggest that fracture rates worldwide could be reduced by 50% if everyone were to achieve a minimum 32 ng/mL vitamin D blood level.

I’m going to keep an eye out for even more research.

References:

Abrahamsen, B and Vestergaard, P. 2010. Declining incidence of hip fractures and the extent of use of anti-osteoporotic therapy in Denmark 1997-2006. Osteoporosis International, 21:373-80.

Brown, Susan E. 2008. Vitamin D and fracture reduction: An evaluation of the existing research. Alternative Medicine Review, 13(1).

Squat toilets and rising fracture rates

December 2, 2010/0 Comments/in Fractures & Healing /by Dr. Susan E. Brown

You might have heard it said that it’s not what we do “once in a while” that matters, but what we do most of the time that is most important. You know, I think this is true, and we can see it when we look at how different cultures perform some of the most basic tasks. And right now, I’m going to talk about a really basic task and how it affects bone health — humor me for a moment so I can tell you about the difference between Western “throne” toilets and Asian squat toilets.

At a recent international bone meeting (ASBMR), there was extended discussion of the rising hip fracture rates in newly developing countries, particularly in Asia. High on the list of concerns is an expected tsunami of hip fractures in China as that country industrializes. This happened in Hong Kong, Singapore, and Japan, where hip fracture rates among the elderly are now often similar to Western rates, where in pre-industrial times they were less common.

The question of why Asian fracture rates dramatically increase with industrialization was open to speculation. Some saw it as a result of the move from field to factory, which reduced physical activity. Some suggest lower vitamin D levels were responsible, while others pointed at higher rates of smoking, more people drinking colas and eating fast food instead of traditional food and drinks, and so on. But then, one researcher suggested that the increasing fracture rates could be attributed in part to the move from traditional “squat” toilets — basically, a simple hole in the floor with a cover and a pipe leading to the sewer outflow — to modern “throne” toilets. Now this got me thinking about simple activities like squatting, and I wondered just how many of us here in the West could even get down to, and up from, a squat toilet just once, much less several times a day?

Musing on this, I remembered the Mexican Aztec descendants I worked with decades ago in remote areas of Acapulco. They had little furniture and would spend much of their “time off” squatting (with heels on the ground) while chatting, drinking a homemade cactus brew, and just relaxing. In a similar fashion, the Japanese traditionally sat on the floor. A traditional Japanese housewife could move with grace and fluidity from a standing position to bended knees, without spilling, to serve tea to a companion sitting on the floor. Even today in Pakistan, the tradition is to sit on the floor to eat and, of course, to use a squat toilet, as I was told by a Pakistani doctor at the ASBMR meeting. Now, if you were to undertake any of these habits for some time, you will note the strength, balance and flexibility required — and most of us in the West just don’t have it any more.

So how does all this relate to increasing fracture rates in China? Here’s a hint. As hip fractures increased in Hong Kong, so did the rate of fragility and falls (there’s been a 50% increase in falls over the last three decades, in fact). My bet is that while many factors are at play, the most predominate drivers are declines in physical strength, flexibility, and balance, leading to more falls and thus more fractures. What do you think? Let me know.

$Heartburn medications and higher risk of fracture$

Increased fracture risk with heartburn drugs

May 26, 2010/0 Comments/in Fractures & Healing /by Dr. Susan E. Brown

Over the years I have written about the many studies documenting an increase risk of fracture among those using strong medications for heartburn. In 2010 the FDA issued a warning that indeed fracture risk is increased by use of proton pump inhibitor heartburn medications. As of today, the FDA mandates that these drugs carry a label warning of increased fracture risk. This group of blockbuster antacid drugs includes Prevacid, Prilosec, and Nexium.

The FDA suggests those taking prescription proton pump inhibitors consult with their doctors and those using such drugs over-the-counter limit their use to no more than three 14-day periods a year.

I suggest that those with digestive issues work to seek and correct the cause of acid indigestion.

Causal factors can include:

• food sensitivities
• weakened digestion
• imbalanced intestinal flora
• H. pylori overgrowth in the stomach
• stress

One way to begin is by keeping a food diary charting the relationship between heartburn and your diet. I have also seen many cases of heartburn resolve with my simple Ten steps to stronger digestion guidelines.

Keep your gut happy and your bones will thank you!

How Mary healed her broken leg fast

May 21, 2010/0 Comments/in Fractures & Healing /by Dr. Susan E. Brown

In an earlier blog post, I told the story of Mary, a young woman who had shattered two bones in her leg in what should have been a fairly minor fall. I’d like to briefly revisit that story now, because Mary’s recovery illustrates points I made in my article on how to speed fracture healing.

Mary had an extremely serious injury to her bone. The only way it could possibly have been more serious would be if the bone had broken through the skin! Her body had a tremendous amount of work to do to knit that bone back together, even with the aid of the plates and pins holding it in place. And Mary was told at the outset that it would take at least a year, if not longer, for her bones to knit completely.

But what Mary’s doctors didn’t know was that she was determined to get back on her feet as quickly as possible, and for her, that meant finding a way to maximize her bones’ capacity to heal. That’s when Mary started the Better Bones protocol of 20 key nutrients, coupled with an alkaline diet and stress reduction (without exercise, at first, because exercising the damaged leg wasn’t really possible).

Mary’s x-rays (below) show the course of her healing from the time of the accident in February of 2009 to December 2009 (the middle x-ray was taken in June, just about 3 months after the accident). We’ve highlighted the striations of the original fracture in red on the February x-ray so you can see where the bones actually broke. It was about 6 weeks after the break that Mary started to make the dietary changes I suggested and take the Better Bones supplements I recommended to her. Later on, after her doctors approved, she started doing some gentle weight-bearing exercises to further promote bone-building activity.

In the x-ray taken in June, you can still see the lines of the fracture (red arrows), but they’re fainter and much less clearly defined. Some of the narrower sections of the break are no longer visible. At that time, Mary told me, her doctor expressed surprise at how fast she was healing, and when she explained about the Better Bones program she was on, told her that “whatever she was doing, it worked, so she should keep doing it.”

Six months later, in December of 2009, the x-ray shows bones that are completely healed — at least two and a half months ahead of schedule, maybe more, since there were no x-rays taken between June and December.

Now it’s true, Mary is a young woman, and the young tend to heal quickly. But let’s not forget, Mary was vitamin D deficient, had some hormonal imbalance, and was under a great deal of stress even before her accident. Her body’s healing mechanisms might have been more dynamic than an older person’s, but they were also coping with more than just the task of building bone — so the speed of her recovery can’t just be attributed to youthful vigor. I would argue that the supplements and the dietary protocol Mary used to support her bones’ healing capabilities was the major reason she was able to recover so quickly — far more quickly than her doctors expected.

Mary’s broken leg – Part 1

April 7, 2010/0 Comments/in Fractures & Healing /by Dr. Susan E. Brown

I often say it’s never too late to build strong, healthy bones, but I could just as easily say it’s never too early! Here’s a case that illustrates that point.

Recently I did a consultation with a young woman from Maine who’d had a severe, and rather strange, leg fracture. Mary is 27, active, and mostly healthy, if a little overweight. In February of 2009, she was standing in line at a skating rink (wearing rollerskates) when someone behind her fell and knocked her down. She doesn’t recall falling particularly hard, yet a sudden, excruciating pain in her leg turned out to be a bone fracture. But this was not just a garden-variety fracture — her right tibia and fibula were shattered. Repairing them would require 16 screws and two metal plates inserted surgically to hold the bone together, followed by months of rehabilitation. I spoke to her by phone after the accident and encouraged her to use the 20 key bone-building nutrients to speed her healing along.

After she was healed, Mary came back to me for a consultation because the extensive damage to her leg had her worried. Why had such a simple fall caused her such serious damage? Friends of hers had had much less injury with similar falls, or even worse falls, than the one that shattered her leg bone. What was going on? Was she at risk of another serious fracture if she fell again?

When we first sat down to review her medical history, about 9 months after the initial accident when she was pretty well healed up, I asked if she’d had a bone scan or a vitamin D test when she was first evaluated by the bone specialist who’d repaired her leg. She hadn’t, so I suggested she go back to her own doctor and ask for both tests. When we looked at the results, there was one point that stood out: her DEXA showed that her bone density was normal for a woman her age, but her vitamin D was surprisingly low — only 24 ng/mL, and this was after she’d been taking close to 3000 IU daily for many months.

If you’ve been reading my blog posts, you already know that Vitamin D deficiency has a huge impact on bone strength. I felt certain that this was one piece of the puzzle. Unfortunately, Mary’s vitamin D status before the accident was unknown, because her doctor, like many others, doesn’t routinely test his patients’ vitamin D levels. But if Mary was this low after supplementing for many months, it’s realistic to think she was even lower last spring after going through a Maine winter with no extra vitamin D.

But there was more to her story. Mary also told me that she’d gone to her doctor not long before the break because of dysfunctional uterine bleeding and highly irregular periods. Estrogen-based birth control pills did nothing to change it — and at around the same time she broke her leg, her menstrual cycles stopped altogether. When they resumed, six months after the accident, she was prescribed progesterone-based birth control pills that seemed to address the issue — her menstrual cycles became regular again. These hormonal irregularities offered another clue: it was likely that added progesterone was what brought Mary’s menses into balance, and low progesterone might be linked to her leg fracture. Years ago, endocrinologist Dr. Jerilynn Prior reported that 25% of all young women in North America suffered from hidden ovulatory disturbances resulting in low progesterone levels and subsequent sub-optimal bone mass development. So now I started wondering why she might experience progesterone deficiency and if there were other hidden endocrine disorders contributing to her menstrual irregularities. Could a thyroid, adrenal, or other sex hormone imbalance be affecting her bones? I asked if she’d had any hormone tests, and she said her thyroid was tested. Her doctor had reported that she’d had a “normal” TSH at her last visit… but the records didn’t specify the exact TSH level. So that’s another place for us to look, since different physicians have different (and sometimes erroneous) ideas of what’s “normal.” No other hormones were tested.

Mary is also working full time and attending graduate classes to obtain a Master’s degree in public policy. She told me that her irregular periods started about the time she moved out of her parents’ house (she has a big, close-knit family) and started living on her own. This raised a red flag for me that stress, and the stress hormone cortisol, could also be an issue here.

Right now, Mary is increasing her dose of vitamin D to around 7000 IU per day (the usual protocol when vitamin D is severely depleted is to take 50,000 IU a week for 8 weeks, then retest to see if it’s gone up). When she goes back for her vitamin D retest, she’s planning to request several of the other tests I recommend to look for signs of bone loss: ionized calcium, intact parathyroid, NTx bone resorption test, and if available, free cortisol and DHEA tests to see whether excess stress hormones are a piece of the puzzle. Mary is still in her bone-building years, so being proactive right now to find out why her bones are weak may save her a lot of trouble later.

This particular case is of interest to me because it’s not often that we see this kind of bone weakness in a young person — but I strongly suspect it’s becoming a lot more common than most of us might wish. We have a lot of bone-weakening factors in our modern lifestyles and diets, not to mention high levels of stress! I’ll be coming back to this case from time to time to talk about what we can learn from it, but for now, I think the take-away is this: bone health isn’t just a concern for older people. There are so many risk factors that can contribute to weak bones that it’s worth stopping to take a look at them and think about which ones you can change right now. Because every little bit helps!

3 tips to help heal fractures

March 2, 2010/0 Comments/in Fractures & Healing /by Dr. Susan E. Brown

Breaking a bone can stop us all in our tracks, no matter what age we are. But particularly for women in their 60’s, 70’s, and 80’s, a fracture can come with a lot of fear and, worst of all, the feeling of helplessness. With 9 million osteoporotic fractures occurring every year, you should know that you can do more than just sit back and let it heal. We have much more influence over the healing process than many practitioners convey. Everything from what you eat to how you move can speed or slow down healing.

Here are three ideas that will have you on a fast track to heal your fracture

1. Aspirin and ibuprofen slow healing. What do you reach for when you’re in pain? So many of the people I talk with at the Center for Better Bones say aspirin and ibuprofen are their first choices when in pain. But these anti-inflammatory medications can delay the healing process. Inflammation is an important part of the cleaning and re-building process of healing a fracture. Ibuprofen and aspirin inhibit this necessary inflammation and therefore delay healing. A better choice for pain relief would be acetaminophen (brand name Tylenol). And I always suggest more natural supplements like vitamin C, quercetin, and omega-3 fatty acids.

2. Your body requires more nutrients, protein, and calories. Fracture healing requires a lot of energy and can increase your metabolism significantly. Depending on the injury, your body could require up to double your normal caloric intake! Protein is particularly important during this time because about half of bone is comprised of protein. The protein matrix is where mineral crystals (the other half of bone) are laid to build strength. Supplementing your diet with minerals like zinc, copper, calcium, phosphorus, and silicon will give your body the building blocks for strong new bone. Vitamins C, D, K, and B6 also specifically help in the bone building process. So don’t skimp on alkalizing fruits, vegetables, nuts, seeds, and quality protein.

3. Exercise may be a good thing. Though it may seem like the last thing on your list, exercising is a key component to speeding fracture healing. For one thing, it increases blood flow to the fractured area, flooding the area with more nutrients to help with healing. Joint loading also prompts the bone to increase matrix synthesis. Of course you’ll want to avoid direct stress on the broken bone, but try range of motion, tendon-gliding, and joint-loading exercises — talk to your practitioner about specific exercises, or get a referral for physical therapy.

There are many other things you can do to speed fracture healing. For more detailed information, read my full article on how to speed fracture healing. You’re not helpless when it comes to healing a fracture. Give yourself a hand with the right bone support.

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Repeat fractures vs. first fractures

January 22, 2010/0 Comments/in Fractures & Healing /by Dr. Susan E. Brown

The nine million osteoporotic fractures that occur worldwide each year give us reason for concern, and recently colleagues to the north asked two interesting questions about who fractures and how much.

How much of the Canadian fracture burden occurs in folks with an osteoporotic bone density, and how much in those with osteopenic or normal bone density?

This question has been asked before, and the Canadian answer was similar to results from around the world — the majority of all Canadian low trauma, “osteoporotic” fractures among both women and men actually occur in folks who have osteopenia or even normal bone density. While those with an osteoporotic bone density have a higher fracture rate, more people have osteopenia, so most fractures occur in this group.

How much of the fracture burden is attributable to first versus repeat fractures?

This inquiry I rate as both original and insightful. So what would be your guess — mostly first fractures perhaps? Yes, using data from the 8-year follow-up Canada wide CAMOS study, researchers found that indeed most fractures were first fractures, but surprisingly a full 40% of all fractures in women and 25% in men were repeat fractures.

Further, repeat fractures occurred in equal proportions among those with osteoporosis and those with osteopenia. We’ve been told before that having a past fracture is one of the best predictors of future fracture, but I believe that we’re just starting to understand that the first low-trauma fracture is likely a screaming red flag regardless of your bone density, and a sign that you need to take action to support your bone health. (For those interested in avoiding any fracture, we suggest you look at our Bone Health Profile).

Reference:

Langsetmo, L, Goltzman, D, et al. 2009. Repeat low-trauma fractures occur frequently among men and women who have osteopenic BMD. J Bone Miner Res, 24(9):1515-1522.

How do I know if I have a spinal fracture?

December 3, 2009/0 Comments/in Fractures & Healing /by Dr. Susan E. Brown

At the Center for Better Bones, I frequently see middle-aged women who have just received a bone density test and have been told they have the bones of an “80-year-old” or something equally frightening. Many become terrified, and some start to wonder if that lower back pain they experience from time to time could really be from a dreaded spinal fracture. Usually this isn’t the case, but the worry created by the medical pronouncement can produce long-term damage, both physically and emotionally. So I always recommend finding out whether there really is any existing spinal fracture, or even any slight deformity. This can now be done by a special x-ray test known as the “Vertebral Deformity Assessment” or the “Vertebral Fracture Assessment.”

Just like the bone density test, the Vertebral Deformity Assessment uses special x-ray beams to image the bone. In this case the x-ray is able to image each vertebral body of the spine detecting if any are crushed, wedged, or in any way deformed or fractured. The Vertebral Deformity Assessment can be done on the newer bone density testing machines that have special software for this purpose. For this test, a side or lateral view of the spine is used. This new spinal x-ray can also be done and interpreted by knowledgeable radiologists using other x-ray technology.

If you do have vertebral fractures, take heart: this is your chance to take action to strengthen your bones. It’s never too late to alter lifestyle factors and improve your nutrition in ways that halt bone loss and begin to build new bone. And if you don’t have vertebral fractures but are still concerned about your overall fracture risk, use our Bone Health Profile to determine your likelihood of future fractures — you may find that you’re in better shape than you think!

How to change your fracture risk

November 25, 2009/0 Comments/in Fractures & Healing /by Dr. Susan E. Brown

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 my Better Bones Program 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.