Stroke Survivors Need to Pay Attention to Bone Health

People who have had a stroke, and the doctors who treat them, have a lot to be concerned about: regaining mobility and function, controlling risk factors for a second stroke, guarding against depression that can result from a newly limited life.

There’s another potential consequence not on everyone’s list: osteoporosis.

“We don’t know as much about osteoporosis and stroke as we should,” said Dr. Mark Goldberg, a neurologist at the Peter O’Donnell Brain Institute in Dallas and professor at the UT Southwestern School of Medicine. “As stroke doctors, this is something we should be paying more attention to.”

Osteoporosis is a progressive disease, more often in women, in which bones become porous and fragile, increasing the risk of fractures. A stroke occurs when blood supply to part of the brain is blocked by a clot or a rupture, killing brain cells and impairing body function, even causing paralysis on one side of the body.

The two maladies are intertwined, and not in a good way. Studies indicate stroke survivors who lose some of their balance and mobility are more likely to fall, and those with osteoporosis have a greater danger of breaking bones.

A Canadian study, for example, concluded stroke patients were 47% more likely than people without a history of stroke to suffer a fracture, a particularly perilous consequence for older people.

“Even if it’s just a small fall, they’re just much more likely to break their hip or shoulder,” Goldberg said. “This is a significant cause of disability.”

Becoming sedentary can make osteoporosis worse. Physical activity is a key factor in maintaining healthy bones, Goldberg said, “and by not moving around, people are likely to lose bone mass. So, after a stroke you’re (more likely to develop) osteoporosis.”

Despite that, other post-stroke problems seem to take priority.

“When people come for follow-up, they’re asked about blood pressure or heart issues,” said Dr. Angela Cheung, an internal medicine specialist and founding director of University Health Network Osteoporosis Program in Toronto. “Bone health is really on the bottom of the list.”

Cheung co-authored a study of more than 16,000 stroke survivors in Canada over 65, examining whether they were screened or treated for osteoporosis in the first year after the stroke.

The results, published earlier this year in the journal Stroke, showed only 5.1% had bone mineral density testing. About 15% were prescribed medication for osteoporosis.

Cheung said the study highlights the need for making osteoporosis assessment standard after a stroke.

“At the least we need to ask, have you fallen, and have you had a fracture, and then incorporate this in our follow-up care,” she said. “This needs to be on everyone’s radar.”

Goldberg agreed. “People who have had a stroke have a lot of problems that need attention,” he said. “All of a sudden you’re in a different world, and patients and their families are often overwhelmed.”

According to research, about one in five people who have a stroke will have another one within five years.

Neurologists, Goldberg said, tend to be focused on preventing a second stroke by controlling such risk factors as high blood pressure, diabetes, high cholesterol and an irregular heartbeat.

“This may be part of the reason that the osteoporosis facet of care hasn’t received enough attention,” he said. “But there are good ways to screen for it, and treatments for people at risk.”

Stroke and osteoporosis have another thing in common: an excellent reason to avoid cigarettes.

“Smoking is a risk factor for osteoporosis and for stroke,” he said. “So that’s a double whammy.”

Source: HealthDay

Osteoporosis — What are your risks?

You might not think of bones as being alive, but they are. Every day, your body breaks down old bone and replaces it with new bone. As you get older, however, the ratio becomes unequal: more bone is lost than gained. If too much is lost, then you can develop the bone disease osteoporosis.

Osteoporosis can cause bones to become weak, brittle and prone to break. Due to loss of bone tissue, bones that were once dense and strong can be unable to withstand the stress of even normal activity, such as bending over or coughing. Osteoporosis-related fractures most commonly occur in the spine, wrist and hip. In addition to bone fractures, osteoporosis can cause bone pain, loss of height and a stooped posture. All of these symptoms can lead to feelings of anxiety and depression.

No one can say for sure which individuals will develop osteoporosis. But research has revealed what makes some people more likely than others to develop it. That’s why it’s important to be aware of the risk factors — and what you can do about them.

Bone health basics

Generally speaking, the risk of developing osteoporosis and being more prone to bone fractures depends on your bone health — the size and strength of your bones and the condition of your bone tissue. Bone health is a result of how well your skeleton developed during childhood and early adulthood, as well as your peak bone mass — the maximum amount of bone tissue you have. Most people achieve peak bone mass in their late 20s to early 30s. Bone health is also affected by how rapidly bone mass is lost as you get older.

Risk factors that can’t be changed

Some risk factors for osteoporosis, such as your age and family history, aren’t things you can control. But just because you’re at risk doesn’t mean you will get the disease. You can monitor your bone health for early signs of abnormal bone loss and take steps to prevent osteoporosis or to slow its development.

These are common risk factors for osteoporosis:

Age. The older you are, the more likely you are to develop osteoporosis and the more likely you are to break a bone because of it. After you’ve reached your peak bone mass, it’s normal to begin losing a small percentage of bone mass each year. This happens because new bone formation slows with age, while bone breakdown stays the same or increases. The internal structure of bones also begins to weaken, and the outer shell thins.

Gender. Women usually have lower peak bone mass than men do. Women also tend to live longer. So, in effect, women have less bone to lose but more time to lose it. In addition, during menopause, women experience a drop in estrogen levels, which usually accelerates bone loss. Osteoporosis is most common among postmenopausal women.

Ethnicity. Caucasians and Asians are at greater risk of osteoporosis; Hispanics and Native Americans appear to have an intermediate risk, while African-Americans have the lowest risk. These various levels of risk are based in part on differences in bone mass and bone density.

Genetics. Family history is a strong predictor of low bone mass. If your mother, sister, grandmother or aunt has osteoporosis, then you’re at greater risk. But remember that having a family history of low bone mass doesn’t automatically mean the same thing will happen to you. By taking steps to lower your risk, osteoporosis can be prevented.

Body frame size. Men and women with small body frames tend to have a higher risk because they usually have less bone mass to draw from as they age.

Health-related risk factors

Individual health circumstances, including health conditions and medications, can influence osteoporosis risk.

Childbearing. Pregnancy builds stronger bones by raising estrogen levels and increasing weight. Bone density decreases slowly during pregnancy and more rapidly while nursing a baby, but this bone loss recovers within six months after stopping nursing in most women.

Medications. Certain medications can accelerate bone loss and increase your risk of osteoporosis. If you take any of the following medications, then talk to your health care professional about what you can do to counteract their effects on bone health.

  • Corticosteroid medicines. Long-term use of corticosteroids, including prednisone (Rayos), cortisone, prednisolone (Orapred, Prelone, others) and dexamethasone (Maxidex, Tobradex, others), lowers bone mass. If you take one of these medications for more than a few weeks, then your doctor will likely monitor your bone density and recommend preventive measures.
  • Anticonvulsants. If you take a medication to control seizures (anticonvulsants) over a long period of time, then your liver begins to metabolize vitamin D in a way that causes a deficiency of the vitamin. If you take an anticonvulsant medication, such as phenobarbital (Lumina), carbamazepine (Carbatrol, Tegretol, others) or phenytoin (Dilantin, Phenytek, others), then your health care professional may recommend vitamin D and calcium supplements.
  • Thyroid medicines. When used in excessive quantities, thyroid medications such as levothyroxine (Synthroid, Tirosint, others) can cause high thyroid hormone blood levels that accelerate bone loss.
  • Diuretics. These drugs prevent fluid buildup in your body. But by doing so, certain diuretics can cause the kidneys to excrete too much calcium, leading to weaker bones.
  • Other drugs. Certain blood thinners, such as heparin, can cause bone loss when used over a long period of time. So can aromatase inhibitors, a class of drugs used to treat breast cancer, and drugs that are used to treat endometriosis and prostate cancer (gonadotrophin-releasing hormone agonists).

Medical conditions. Certain medical conditions can increase the risk of osteoporosis by slowing bone formation or speeding up bone breakdown. They include:

  • Endocrine disorders, such as hypogonadism, overactive thyroid (hyperthyroidism), hyperparathyroidism, Cushing’s syndrome and diabetes
  • Gastrointestinal disorders, including Crohn’s disease, celiac disease, lactose intolerance and liver disorders such as primary biliary cirrhosis
  • Rheumatoid arthritis
  • Absent or infrequent menstrual cycles in women of childbearing age

Gastrointestinal surgery. Surgery to reduce the size of the stomach or to remove part of the intestine limits the ability of these organs to absorb nutrients, including calcium.

Risk factors you can change

Although the risks may seem daunting, it’s important to realize there are some risk factors for osteoporosis that you can control. It’s never too late to do something about your bone health.

Low calcium and vitamin D intakes. A lifelong lack of calcium plays an important role in the development of osteoporosis. Low calcium intake contributes to diminished bone density, early bone loss and an increased risk of fractures. Because vitamin D is essential for calcium absorption, chronically low levels can contribute to osteoporosis. Some studies suggest that large portions of the U.S. population may have low levels of vitamin D. But the data is difficult to interpret, because the definition of what constitutes deficiency can vary. Still, it’s a good idea to have your vitamin D level checked if are in one of the categories of higher risk of deficiency.

Eating disorders. Severely restricting food intake and being underweight can weaken bone.

Lack of physical activity. Regular physical activity is key to preventing osteoporosis and fractures. Lack of exercise accelerates bone loss; whereas, weight-bearing exercises such as walking and resistance training can increase or at least maintain your bone density at any age.

Smoking. Here’s another good reason to quit — smoking is bad for your bones. Smoking interferes with the production of estrogen and testosterone, which are needed to build bone. Smoking also disrupts calcium absorption.

Alcohol use. Alcohol delivers a double whammy to your bones, putting a damper on bone building and stimulating the bone loss process. If you choose to drink alcohol, do so in moderation. For healthy adults, that means up to one drink a day for women of all ages and men older than age 65, and up to two drinks a day for men age 65 and younger.

Source: Mayo Clinic

Many Stroke Patients Not Screened for Osteoporosis, Despite Known Risks

The majority of stroke survivors are not screened or treated for osteoporosis, broken bones, or fall risk — despite stroke being a risk factor for these conditions. The risk is up to four times greater than in healthy people, according to new research in the American Heart Association’s journal Stroke.

Stroke survivors often face reduced mobility — a trait that decreases bone mineral density and increases risk for bone breaks.

Less than one-third of older women living in the United States are screened for osteoporosis and the treatment rate for some high-risk patients tops out at 30 percent.

“Our study adds to previous research that found despite an increased risk, only a small number of people who have recently had a stroke are tested and treated for osteoporosis,” said Moira Kapral, M.D., M.Sc., FRCPC, lead author of the study and professor of medicine and director of the division of general internal medicine at the University of Toronto in Canada.

Researchers identified stroke survivors age 65 and older who either had visited the emergency department or had been hospitalized for strokes (ischemic or intracerebral hemorrhage) between July 1, 2003 and March 31, 2013 at 11 regional stroke centers throughout Ontario, Canada from the Ontario Stroke Registry. Using administrative databases allowed researchers to link the registry with information about bone mineral density testing, prescription medications and deaths.

Of the 16,581 stroke survivors included in the study, only:

  • 5.1 percent had bone mineral density testing;
  • 15.5 percent were prescribed medications for osteoporosis within one year after stroke; and
  • a small percentage of stroke survivors were prescribed medications for osteoporosis for the first time.

The study also found that, while overall screening and treatment for osteoporosis and related conditions was low, certain stroke survivors were more likely to have bone mineral density testing. These people tended to be younger, female and to have had low-trauma fractures in the year after their stroke. Patients were more likely to be prescribed medications for osteoporosis post-stroke if they were female, already had osteoporosis, had previously broken bones, had previously had bone mineral density testing and had fallen or broken bones after their stroke.

“This study offers more evidence that there is a missed opportunity to identify people with stroke at increased risk of fractures, and to initiate treatment to prevent bone loss and fractures,” Kapral said.

Source: American Heart Association


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Study: People with Osteoporosis Should Avoid Certain Spinal Poses in Yoga

Rhoda Madson wrote . . . . . . . . .

Yoga postures that flex the spine beyond its limits may raise the risk of compression fractures in people with thinning bones, according to research from Mayo Clinic. The results appear in Mayo Clinic Proceedings.

Researchers at Mayo Clinic and elsewhere have described injuries from yoga. This study examines injuries in people with osteoporosis and osteopenia — conditions characterized by low bone density.

Osteoporosis is a disease in which bones become thinner and more porous from loss of mineral content. Bone loss that has not reached the stage of an osteoporosis diagnosis is called osteopenia.

Researchers reviewed the health records of 89 people — mostly women — referred to Mayo Clinic from 2006 to 2018 for pain they attributed to their yoga practice. Some were new to yoga. Others had practiced for years. They had pain in the back, neck, shoulder, hip, knee or a combination.

Patients identified 12 poses they said caused or aggravated their symptoms. The most common postures involved extreme flexing or extending of the spine. Researchers used patients’ health records, medical exams and imaging to confirm and categorize the injuries as soft tissue, joint or bone injuries.

Researchers identified 29 bony injuries, including degeneration of disks, slippage of vertebrae and compression fractures. The latter appeared to be related to postures that put extra pressure on the vertebra and disks.

“Yoga has many benefits. It improves balance, flexibility, strength and is a good social activity,” says Mehrsheed Sinaki, M.D., a Mayo Clinic physical medicine and rehabilitation specialist and the study’s senior author. “But if you have osteoporosis or osteopenia, you should modify the postures to accommodate your condition. As people age, they can benefit by getting a review of their old exercise regimens to prevent unwanted consequences.”

Patients who incorporated recommendations to modify their movements reduced their pain and improved their symptoms.

In a separate commentary, Edward Laskowski, M.D., co-chair of Mayo Clinic Sports Medicine, called on providers, patients and yoga teachers to work together to produce an individualized exercise prescription that considers the yoga student’s medical history to protect against injury and provide optimal benefit.

The authors noted study limitations. The patients were seen in a musculoskeletal clinic at a tertiary care center, which makes generalizations difficult. Researchers received follow-up reports on 22 patients, as most lived out of state.

Source: Mayo Clinic


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Osteoporosis Often Missed in Elderly Men

Osteoporosis is typically thought of as a woman’s disease, but elderly men are also prone to bone loss — even though they often aren’t treated for it, a new study finds.

Among men and women aged 80 and older, women were three times more likely to get osteoporosis treatment, researchers reported.

Ten million Americans have osteoporosis, according to the study. Each year, the disease causes 2 million fractures, costing $19 million. As the population ages, this could rise to 3 million fractures at a cost of $25 million by 2025.

Osteoporosis is a serious condition for men, too, the researchers added. After breaking a hip, the risk of illness and death is greater among men than women, they noted.

For the study, researchers led by Dr. Radhika Rao Narla, from the Division of Metabolism, Endocrinology and Nutrition at the University of Washington in Seattle, compared screening and treatment for osteoporosis among more than 13,700 men and women aged 70 and older.

Managing the disease included scans of bone mineral density, measuring levels of vitamin D, and treatment with vitamin D, calcium supplements and bisphosphonates (some brand names include Boniva, Actonel and Fosamax).

The investigators looked at more than 11,600 men and 460 women where age alone was a risk factor for hip fracture, and another group of more than 1,600 men at risk for osteoporosis due to previous fracture or treatment that weakened bones.

About 50 percent of the men aged 75 to 79 had a risk of breaking a hip that qualified them for osteoporosis treatment, as did 88 percent of the men aged 80 and older.

The researchers found that men were much less likely than women to be tested and treated for osteoporosis, especially those aged 80 and older.

Looking at age alone, the researchers found that more women than men had their bone density measured (63 percent versus 12 percent) and had their vitamin D levels measured (39 percent versus 18 percent).

Women were more than three times as likely to be given calcium and vitamin D supplements (63 percent versus 20 percent) and to be treated with bisphosphonates (44 percent versus 5 percent), the researchers found.

Among men aged 80 and older, only 10 to 13 percent had bone density measured and fewer than 1 in 10 were treated with bisphosphonates.

Men at higher risk for hip fractures or those who had already suffered from a broken hip were often overlooked for diagnosis and treatment, the researchers noted.

Narla and her team could not say why men are not assessed for osteoporosis. It might be a lack of awareness of screening guidelines or doctors are busy dealing with other medical problems, they said.

These findings suggest that guidelines are “inadequate in effectively identifying older men who might benefit from evaluation for osteoporosis and fracture prevention treatment,” the researchers said.

The report was published online in the Journal of Investigative Medicine.

“We believe that there is a need for developing strategies to improve the evaluation and management for all older men, particularly among elderly men with a very high risk of fracture,” Narla’s group said in a journal news release.

Source: HealthDay


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